EH Legal Representative Form
Application for Services
State / Province / Region
Postal / Zip Code
DOCUMENTATION TO AUTHORIZE AN OWNER'S LEGAL REPRESENTATIVE
Applications for permits require the "signature of the owner or owner's legal representative" (lSA NCAC 18A .1937). If the owner does not sign the application himself or herself, they can submit any one of the following documents to designate their legal representative:
Power of Attorney
Real Estate Contract
Court Ordered Guardianshop
In the absence of the above documentation,
In the absence of the above documentation, the property owner may provide the local health department with documentation that designates a legal representative. A property owner may: 1) Complete this form to document his or her legal representative, or 2) Provide their own form that contains the information in this form. If there are multiple property owners, then all property owners must sign the form that designates a legal representative. By signing a form that designates a legal representative for purposes of 15A NCAC 18A .1937, the property owner authorizes that representative to act on their behalf in matters pertaining to the application and permitting process, including signing or receiving any application, document or permit. The owner retains full responsibility to meet all permit conditions specified by the local health department.
I am the legal owner(s) of the property located at the address referenced below, identified as Parcel ID number referenced below, located in Rowan County, North Carolina.
I do hereby authorize the legal representative/company name entered below to act as an agent on my behalf in applying for/signing/obtaining any of the documents described below herein: 1) Application for Improvement Permit (IP)/ Authorization to Construct (AC); 2) Improvement Permit (IP)/ Authorization to Construct (AC); 3) Application for soil-site evaluation (new/repair); 4) Application/permit for private drinking water well/well abandonment; 5) Application for Compliance Inspection.
I agree to abode by all decisions and/or conditions between the legal representative acting on my behalf and the Rowan County Department of Public Health, Environmental Health Division.
Legal Owner, Property Address, Parcel ID, Legal Representative
Legal Owner's Name