BRUNSWICK COUNTY CODE ADMINISTRATION
75 Courthouse Drive, Building I
Bolivia, NC 28422
Phone: 910-253-2021
Fax: 910-253-2024
eplans@brunswickcountync.gov
AUTHORIZATION TO PULL PERMITS
DATE: / _/____
LICENSE INFORMATION:
LICENSE NUMBER: _______________________________
COMPANY NAME: _______________________________
QUALIFIER’S NAME: ______________________________
MAILING ADDRESS: ____________________________________________
CITY: _____________ STATE: ________ ZIP: ____________
PORTAL ACCOUNT ADMINISTRATOR’S NAME: ___________
EMAIL
ADDRESS: _______________________________________________
PHONE NUMBER: (___ ) _____________
I give the following individual(s) permission to pull permits under my license:
NAME: _____, PHONE: _____________ , EMAIL: ,
NAME: _____, PHONE: _____________ , EMAIL: ,
NAME: _____, PHONE: _____________ , EMAIL: ,
SIGNATURE:
TITLE:
STATE OF NORTH CAROLINA, COUNTY OF BRUNSWICK
I, a Notary Public of the County and State aforesaid, certify that_____________________________ personally appeared
before me this day, and I have personal knowledge of the identity of the principal(s). I have seen satisfactory evidence of
the principal’s identity, by current state or federal identification with the principal’s photograph in the form of a driver’s
license; each acknowledging to me that he/she/they voluntarily signed the foregoing document for the purpose stated
therein and, in the capacity, indicated: This day of_______________, 20__________.
NOTARY PUBLIC:
(OFFICIAL SEAL)
