58388_MITCHELL, PATRICK_20120125

❑CAMA / ❑ DREDGE & FILL
r.
GENERAL PERMIT Previous permit #
❑New ❑Modification ❑Complete Reissue El Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environment and Natural Resources
and the Coastal Resources Commission in an area of environmental concern pursuant to I SA NCAC
i ❑ Rules attached.
Applicant Name Project Location: County
Address
City
State ZIP
Phone # ()
Fax # ( )
Authorized Agent
Affected ❑ CW
❑ EW ❑ PTA ❑ ES ❑ PTS
AEC(s): ❑ OEA
❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS:
❑ FC:
ORW: yes / no
PNA yes / no Crit.Hab. yes / no
Street Address/ State Road/ Lot #(s)
Subdivision
City ZIP
Phone # () River Basin
Adj. Wtr. Body (nat /man /unkn)
Closest Maj. Wtr. Body
MENNEN
0
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Agent or Applicant Printed
Signature ** Please read compliance statement on back of permit **
Permit Officer's Signature
r
i
t
Issuing Date Expiration Datey
Application Fee(s)
Check# Local Planning Jurisdiction
Rover File Name

0
Statement of Compliance and Consistency
This permit is subject to compliance with this application, site drawing and attached general and specific conditions. Any
violation of these terms may subject the permittee to a fine or criminal or civil action; and may cause the permit to become
null and void.
This permit must be on the project site and accessible to the permit officer when the project is inspected for compliance. The
applicant certifies by signing this permit that 1) prior to undertaking any activities authorized by this permit, the applicant will
confer with appropriate local authorities to confirm that this project is consistent with the local land use plan and all local
ordinances, and 2) a written statement or certified mail return receipt has been obtained from the adjacent riparian
landowner(s) .
The State of North Carolina and the Division of Coastal Management, in issuing this permit under the best available
information and belief, certify that this project is consistent with the North Carolina Coastal Management Program.
River Basin Rules Applicable To Your Project:
❑ Tar- Pamlico River Basin Buffer Rules ❑ Other:
❑ Neuse River Basin Buffer Rules
If indicated on front of permit, your project is subject to the Environmental Management Commission's Buffer Rules for the
River Basin checked above due to its location within that River Basin. These buffer rules are enforced by the NC Division of
Water Quality. Contact the Division of Water Quality at the Washington Regional Office (252-946-6481) or the Wilmington
Regional Office (910-796-7215) for more information on how to comply with these buffer rules.
Division of Coastal Management Offices
Raleigh Office
Mailing Address:
1638 Mail Service Center
Raleigh, NC 27699-1638
Location:
2728 Capital Blvd.
Raleigh, NC 27604
919-733-2293
Fax:[phone]
Morehead City Headquarters
400 Commerce Ave
Morehead City, NC 28557
252-808-2808/ 1-888-4RCOAST
Fax: [phone]
(Serves: Carteret, Craven, Onslow -above
New River Inlet- and Pamlico Counties)
Elizabeth City District
1367 U.S. 17 South
Elizabeth City, NC 27909
252-264-3901
Fax:[phone]
(Serves: Camden, Chowan, Currituck,
Dare, Gates, Pasquotank and Perquimans
Counties)
Washington District
943 Washington Square Mall
Washington, NC 27889
252-946-6481
Fax: [phone]
(Serves: Beaufort, Bertie, Hertford, Hyde,
Tyrrell and Washington Counties)
Wilmington District
127 Cardinal Drive Ext.
Wilmington, NC 28405-3845
910-796-7215
Fax: [phone]
(Serves: Brunswick, New Hanover,
Onslow -below New River Inlet- and
Pender Counties)
Revised 08/09/06

B PRESCOTT MARINE CONSTRUCTION
PO BOX 874 252-249-0149
ORIENTAL, NC 28571
2805
C% 1 66-30/531
472
DATE _ �/�/ /
OLLARS
First Citizens
Bank
FOR l0.I /'ZI yj-&i'?
000 280 5u' i:0 5 3 L00 3001:001, 7 L 20 2049 70

Beverly Eaves Perdue
Governor
January 30, 2012
Patrick Mitchell
c/o Bobby Prescott
P.O. Box 874
Oriental, N.C. 28571
Dear Mr. Mitchell:
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Braxton C. Davis
Director
Dee Freeman
Secretary
Attached is General Permit #58388 C to replace a 100' X 5' dock, a 10' X 20' platform, and a 13' X 13' boatlift
at 187 Lauren Rd., Whortonsville, North Carolina in Pamlico County.
In order to validate this permit, please sign the permit as indicated. Retain the white copy for your files and
return the signed yellow and pink copies to us in the enclosed, self-addressed envelope. If the signed permit
copies are not returned to this office before the initiation of development, you will be working without
authorization and will be subject to a Notice of Violation and subsequent civil penalties.
We appreciate your early attention to this matter.
Sincerely,
Ryan Davenport
Coastal Management Representative
rcb
Enclosures
400 Commerce Ave., Morehead City, NC 28557
Phone: [phone] FAX: [phone] Internet: www.nccoastalmanagement.net
An Equal Opportunity 1 Affirmative Action Employer
NorthCarolina
,vaturallry

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue James H. Gregson Dee Freeman
Governor Director Secretary
BUFFER AUTHORIZATION CERTIFICATE
FOR PIER AND DOCKING FACILITIES ACCESS WAY
A riparian buffer authorization is required for pier and docking facilities access ways through the Tar -Pamlico &
Neuse River Riparian buffer per Division of Water Quality (DWQ) regulations 15A NCAC 0213.0233 & .0259.
The Division of Coastal Management (DCM), through a Memorandum of Understanding with the Division of
Water Quality (DWQ) has reviewed your project proposal, determined that the project as proposed complies
with the aforementioned regulations, and made a "no practical alternatives" determination per those
regulations.
Those activities covered by your Coastal Area Management Act (CAMA) permit have received Buffer
Authorization as long as the project is constructed in a manner that continues to meet all of the conditions
listed below. Failure to comply with this Buffer Authorization shall subject the property owner & the party
(contractor) performing the construction Wor land clearing to a civil penalty of up to $25,000 per day per
violation.
1. Crossing is Perpendicular: Pier and docking facility access way must cross the 50 ft. riparian buffer
perpendicularly (which is defined as between 75 and 105 degrees) unless otherwise approved by DCM.
The alignment shall minimize the removal of woody vegetation to the greatest extent practicable.
2. Pervious Materials: All reasonable measures shall be taken to ensure the access way is made of
pervious materials like open -slatted wood or composite, mulch, or grass to meet the intent of the rules
to the maximum extent practicable.
3. Access Width: The width of the pier or docking facility access way shall be limited to six (6) feet.
4. Project Drawing: The drawing on the CAMA General Permit is considered the project drawing of your
property indicating the relative location of the pier or docking facility and any requested access way.
This drawing will be used to aid in compliance and monitoring efforts.
By your signature below you agree to be held responsible for meeting all of the conditions listed above and
verify that all information provided is complete and accurate.
116 r-o hCl r � 6be✓4Soh
Agent or Applicant Printed Name
�if?w P Rl,��A,�
Agent or Applicant Signature
CAMA GENERAL PERMIT #:
Washington Office
943 Washington Square Mall
Washington, NC 27889
Phone [phone]
Morehead City Office
400 Commerce Avenue
Morehead City, NC 28557
Phone [phone]
Permit Officer's Signature
Issue Date
An Equal Opportunity/Affirmative Action Employer — 50% Recycled/10% Post Consumer Paper
Version 5, 09/2009

SECTIO'v .1200 - GENERAL .PERMIT FOR CONSTRUCTION OF PIERS AND DOCKINfIG
FACILITIES: IN ESTUARINE AND PUBLIC TRUST WATERS AND OCEAN HAZARD
AREAS
15A NCAC 07H .1201 PURPOSE
A permit under this Section shall allow the construction of new piers and docking facilities (including pile supported or
floating) in the estuarine and public trust waters AECs and construction of new piers and docks within coastal wetlands AECs
according to the authority provided in Subchapter 07J . I 100 and according to the Rules in this Section. This permit shall not
apply to oceanfront shorelines or to waters and shorelines adjacent to the Ocean Hazard AEC with the exception of those
shorelines that feature characteristics of the Estuarine Shoreline AEC. Such features include the presence of wetland
vegetation, lower wave energy, and lower erosion rates than the adjacent Ocean Erodible Area.
History Note: Authority G.S. 113A-107(a); 113A-107(b); 113A-113(b); 113A-118.1; 113A-124;
Eff. March 1, 1984;
Amended Eff. July 1, 2009; April 1, 2003.
15A NCAC 07H .1202 APPROVAL PROCEDURES
(a) An applicant for a General Permit under this Subchapter shall contact the Division of Coastal Management and request
approval for development. The applicant shall provide information on site location, dimensions ofthe project area, and his
name and address.
(b) The applicant shall provide:
(1) confirmation that a written statement has been obtained signed by the adjacent riparian property owners
indicating that they have no objections to the proposed work; or
(2) confirmation that the adjacent riparian property owners have been notified by certified mail of the proposed
work. The notice shall instruct adjacent property owners to provide any comments on the proposed
development in writing for consideration by permitting officials to the Division of Coastal Management within
10 days of receipt of the notice, and, indicate that no response will be interpreted as no objection. DCM staff
shall review all comments and determine, based on their relevance to the potential impacts of the proposed
project, if the proposed project can be approved by a General Permit. If DCM staff finds that the comments are
worthy of more in-depth review, DCM shall notify the applicant that lie must submit an application for a major
development permit.
(c) No work shall begin until an on -site meeting is held with the applicant and a Division of Coastal Management
representative to review the proposed development. Written authorization to proceed with the proposed development shall be
issued if the Division representative finds that the application meets all the requirements of this Subchapter. Construction
shall be completed within 120 days of the issuance of the general authorization or the authorization shall expire and it shall be
necessary to re-examine the proposed development to determine if the general authorization may be reissued.
(d) Any modification or addition to the authorized project shall require prior approval from the Division of Coastal
Management.
History Note: Authority G.S. 113A-107(a); 113A-107(b); 113A-113(b); 113A-118.1; 113A-124;
Eff. March 1, 1984;
Amended Eff. October 1, 2007; August 1, 1998; January 1, 1990.
15A NCAC 07H .1203 PERMIT FEE
The applicant shall pay a pen -nit fee oftwo hundred dollars ($200.00) by check or money order payable to the Department.
History Note: Authority G.S. 113,4-107; 113A-113(b); 113A-118.1; 113A-119; 113-119.1; 113A-124;
Eff. March 1, 1984;
Amended Eff. September 1, 2006; August 1, 2000; March 1, 1991..
50

15A NCAC 07FI .1204 GENERAL CONDITIONS
ia) i lets and docking taciiities autflurized ljy :his CIfer'"Al ricnii!t shall be fur th-, cxlauSIVe use o1 the and uwrier, or Occupant
and shall not be ;eased or .rented or used for an,,, commercial puroese. Except in the cases of shared piers as described in %H
1303, viers and decking :aciiities dzsigned tc oro vide : ccking spacz for more than t.,vo boats shall, be,-ause oft?eir greater
potential for adverse impacts, be reviewed through the major pennitting process and, therefore, are not authorized by this
general permit.
(b) Individuals shall allow authorized representatives of the Department of Environment and Natural Resources to make
periodic inspections at any time deemed necessary in order to be sure that the activity being performed under the authority of
this general pen -nit is in accordance with the terms and conditions prescribed herein.
(c) There shall be no interference with navigation or use of the waters by the public by the existence of piers and -docking
facilities.
(d) This permit shall not be applicable to proposed construction where the Department determines that the proposed activity
will endanger adjoining properties or significantly affect historic, cultural, scenic, conservation or recreation values, identified
in G.S. 113A-102 and G.S. 113A-I 13(b)(4).
(e) This permit does not eliminate the need to obtain any other required state, local, or federal authorization.
(f) Development carried out under this permit shall be consistent with all local requirements, AEC Guidelines, and local land
use plans current at the time of authorization.
History Note: Authority C.S. 113A-107(a); 113A-107(b); 113A-113(b); 113A-118.1; 113A-124;
Eff March 1, 1984;
Amended Eff. May 1, 1990;
RRC Objection due to ambiguity Eff. May 19, 1994;
Amended Eff. July 1, 2009; August 1, 1998; July 1, 1994.
15A NCAC 07I1.1205 SPECIFIC CONDITIONS
(a) Piers and docking facilities may extend or be located up to a maximum of400 feet waterward from the normal high water
line or the normal water level, whichever is applicable.
(b) Piers and docking facilities shall not extend beyond the established pier length along the same shoreline for similar use.
This restriction shall not apply to piers and docking facilities 100 feet or less in length unless necessary to avoid interference
with navigation or other uses of the waters by the public such as blocking established navigation routes or interfering with
access to adjoining properties. The length of piers and docking facilities shall be measured from the waterward edge of any
wetlands that border the water body.
(c) Piers and docking facilities longer than 200 feet shall be permitted only if the proposed length gives access to deeper
water at a rate of at least one foot at each 100 foot increment of pier length longer than 200 feet, or if the additional length is
necessary to span some obstruction to navigation. Measurements to determine pier and docking -facility lengths shall be made
from the waterward edge of any coastal wetland vegetation, which borders the water body.
(d) Piers shall be no wider than six feet and shall be elevated at least three feet above any coastal wetland substrate as
measured from the bottom of the decking.
(e) The total square footage of shaded impact for docks and mooring facilities (excluding the pier) allowed shall be 8 square
feet per linear foot of shoreline with a maximum of 800 square feet. In calculating the shaded impact, uncovered open water
slips shall not be counted in the total.
(f) The maximum size of any individual component of the docking facility authorized by this General Permit shall not exceed
400 square feet.
(g) Docking facilities shall not be constructed in a designated Primary Nursery Area with less than two feet of water at normal
low water level or normal water level (whichever is applicable) under this permit without prior approval from the Division of
Marine Fisheries or the Wildlife Resources Commission (whichever is applicable).
(h) Piers and docking facilities located over shellfish beds or submerged aquatic vegetation (as defined by the Marine
Fisheries Commission) may be constructed without prior consultation from the Division of Marine Fisheries or the Wildlife
Resources Commission (whichever is applicable) if the following two conditions are met:
(1) Water depth at the docking facility location is equal to or greater than two feet of water at normal low water
level or normal water level (whichever is applicable).
(2) The pier and docking facility is located to minimize the area of submerged aquatic vegetation or shellfish
beds under the structure.
(i) Floating piers and floating docking facilities located in PNAs, over shellfish beds, or over submerged aquatic vegetation
shall be allowed if the water depth between the bottom of the proposed structure and the substrate is at least 18 inches at
normal low water level or normal water level, whichever is applicable.
0) Docking facilities shall have no more than six feet of any dimension extending over coastal wetlands and shall be elevated
at least three feet above any coastal wetland substrate as measured from the bottom of the decking.
51

('.k) The width requirements established in Paragraphs (d). (e), (f), (g), (h), (i}, and (j). of this Rule shall not apply to pier
itT'1.iCti.ireS in iStCnCe on nr jlt.i./ ' jf Lvi1�n _tn-irtilra nnrii arinnc arm ne?rieri to Y,r-lr�nr or minimi�o :r�r+Y .-- -- -r- - - -
damage. In these cases, pilings and cross bracing may be used to nr o vide structural suUUort asong as ;hey do net extend
more than of t�,-o feet on either side of the principal structure. These -nodiflcat'.ons shall not be Used to expand the floor
decking of platforms and piers.
(1) Boathouses shall not exceed a combined total of400 square feet and shall have sides extending no further than one-half
the height ofthe walls as measured in a downward direction from the top Nall plate or header and only covering the top half
of the walls. itiieasurements of square footage shall be taken of the greatest exterior dimensions. B'oarhotises shall not be
a ,vvvCu on lots vvit,i ,cs3 urn,1 , 5 ultcai icct Gi s,tW c1wc.
(m) The area enclosed by a boat lift shall not exceed 400 square feet.
(n) Piers and docking facilities shall be single story. They may be roofed but shall not allow second story use.
(o) Pier and docking facility alignments along federally maintained channels shall also meet Corps of Engineers regulations
for construction pursuant to Section 10 of the Rivers and Harbors Act.
(p) Piers and docking facilities shall in no case extend more than 1/4 the width of a natural water body, human -made canal or
basin. Measurements to determine widths of the water body, human -made canals or basins shall be made from the waterward
edge of any coastal wetland vegetation which borders the water body. The 1/4 length limitation shall not apply when the
proposed pier and docking facility is located between longer structures within 200 feet of the applicant's property. However,
the proposed pier and docking facility shall not be longer than the pier ]lead line established by the adjacentpiers and docking
facilities nor longer than 1 /3 the width of the water body.
(q) Piers and docking facilities shall not interfere with the access to any riparian property, and shall have a minimum setback
of 15 feet between any part of the pier and docking facility and the adjacent property lines extended into the water at the
points that they intersect the shoreline. The minimum setbacks provided in the rule may be waived by the written agreement
of the adjacent riparian owner(s), or when two adjoining riparian owners are co -applicants. Should the adjacent property be
sold before construction of the pier commences, the applicant shall obtain a written agreement with the new owner waiving the
minimum setback and submit it to the Division of Coastal Management prior to initiating any development of the pier or
docking facility. The line of division of areas of riparian access shall be established by drawing a line along the channel or
deep water in front of the property, then drawing a line perpendicular to the line of the channel so that it intersects with the
shore at the point the upland property line meets the water's edge. Application offthis Rule maybe aided by reference to the
approved diagram in Paragraph (t) of this Rule illustrating the rule as applied to various shoreline configurations. Copies of
the diagram may be obtained from the Division of Coastal Management. When shoreline configuration is such that a
perpendicular alignment cannot be achieved, the pier or docking facility shall be aligned to meet the intent of this Rule to the
maximum extent practicable.
(r) Piers and docking facilities shall be designed to provide docking space for no more than two boats.
(s) Applicants for authorization to construct a pier or docking facility shall provide notice of the permit application to the
owner of any part of a shellfish franchise or lease over which the proposed pier or docking facility would extend. The
applicant shall allow the lease holder the opportunity to mark a navigation route from the pier to the edge of the lease.
(t) The diagram shown below illustrates various shoreline configurations:
52

EXAMPLES
RIPARIAN ACCESS AREAS
tl 11:�1+
PROJECT AREA
I ,
Et)Gl:Of C11ANNEI. OR
1)1 LP WAT I
Y LINE•
PROV1.111
RIPARIAN I.IfrStT
MEAN HIGH 4VATE.R
WATER
(u) Shared piers or docking facilities shall be allowed and encouraged provided that in addition to complying with
(a) through (t) of this rule the following shall also apply:
(1) The shared pier or docking facility shall be confined to two adjacent riparian property owners and the
landward point of origination of the structure shall overlap the shared property line.
(2) Shared piers and docking facilities shall be designed to provide docking space for no more than four boats.
(3) The total square footage of shaded impact for docks and mooring facilities shall be calculated using (e) of
this rule and in addition shall allow for combined shoreline of both properties.
(4) The property owners of the shared pier shall not be required to obtain a 15-foot waiver from each other as
described in subparagraph (q) of this rule as is applies to the shared riparian line for any work associated
with the shared pier, provided that the title owners of both properties have executed a shared pier
agreement that has become a part of the permit file.
(5) The construction of a second access pier or docking facility not associated with the shared pier shall require
authorization through the CAMA Major full review permit process.
History Note: Authority G.S. 113A-107(a); 113A-107(b); 113A-113(b); 113A-118.1; 113A-124;
Eff March 1, 1984;
Amended Eff. December 1, 1991; May 1, 1990; March 1, 1990;
RRC Objection due to ambiguity Eff March 18, 1993;
Amended Eff August 1, 1998; April 23, 1993;
Temporary Amendment Eff. December 20, 2001;
Amended Eff. July 1, 2009; April 1, 2003.
53

UNITED STATES Po qTA Y� sa s sit s si ul c „ ;= First-Clpss Mail
't !s� 4ss� Postage`& Fees Paid
USPS
Permit No. G-10
• Sender: Please print your name, address, and ZIP+4 in this box •
�oct
pc ea YA
Of Nc-
UNITED STATES POSTAL SERVICE First -Class Mail
Postage & Fe6s Paid
USPS
Permit No. G-10
• Sender: Please print your name, address, and ZIP+4 in this box •
c(PSC Ot
o� C �z�s�
t

■ Complete items 1, 2, and 3. Also complete A.
item 4 if Restricted Delivery is desired. x
■ Print your name and address on the reverse
so that we can return the card to you. B.
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
1. Article Addressed to:
.-KnOt
FL'333'
Name) I C.
D. jVckliv(4\ab'dEdWctff4rent from item l? 111 Ye;
If YES, enter delivery address below: ❑ No
3. fRegistered
ice Type
ertified Mail ❑ Express Mail
❑ Return Receipt for Merchandise
❑ Insured Mail ❑ C.O.D.
4. Restricted Delivery? (Extra Fee) ❑ Yes
2. Article Number
(transfer from service label) 7 011 0470 0000 7751 0 617
PS Form 3811, February 2004 Domestic Return Receipt 102595-02-M-1540
0

■ Complete items 1, 2, acid 3. Also complete
item 4 if Restricted Delivery is desired.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
1. Article Addreftc
F/\Cc->K) i
py��3�1a�7
A.
7 / / a 0 Agent
x�� ❑ Addressee
B. Received by (A 'Hied Name) C. Date of Delivery
/L -S =V
D. Is delivery address different from item 1? ❑ Yes
If YES, enter delivery address below: ❑ No
3, Pervice Type
P�Qertifled Mail ❑ Express Mail
Registered 0 Return Receipt for Merchandise
❑ Insured Mail ❑ C.O.D.
4. Restricted Delivery? (Extra Fee) ❑ Yes
2. Article Number 7011 0470 0000 7751 0624
(rransfer from service label) /' n�J
PS Form 3811, February 2004 Domestic Return Receipt %� �fC� 102595-02-M-1540

DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION FORM
CERTIFIED MAIL - RETURN RECEIPT REQUESTED
I hereby certify that I own property adjacent to i?mr I L K 611 +ch c 1 I 's
(Name of Property Owner)
property located at f '= �1 � %D12-
y� (,/ 1 (Address, Lot, Block, Road, etc.)
on //I�Lif�u``� C k in NL t %Ili l) i (1 , P19MU tQ AC.
(Waterbody) (City/Town and/or County) �7�7
Agent's Name #: !E�cciGthti�fft l- t19 f�(>1'Jr�/t' �h Mailing Address: t / 96 � �} 0
4
Agent's phone #: 9-5� -cx 7� 014!1 Ci� lent- " /y1 ;if 2J V
He/She has described to me as shown below the development he/she is proposing at that location,
and I have no objections to the proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
w
its"'"" 11��• V
�� rY) i4k: he i 1 FAC-0 . I
Pip + -propeV� 1�POPERr�
If you have objections to what is being proposed, you insist notify the Division of Coastal Management
(DCM) in writing within 10 days of receipt of this notice. Contact information for DCM offices is
available at www.nccoastalmangement.net/contact dcm.htm or by calling 1-888-4RCOAST. No
response is considered the same as no objection if you have been not>Fed by Certifiled Mail.
(Property Owner Information)
Signature
-AO s / -- F� CZ Av/
Print or Type Name
-3 9 Fit--14A1eC-n1-r' R-,)
Mailing Address
I- 6AIIX ►111,4--Y ,A! f d 7 85-3
City/State2ip
974, 4 l e3
Telephone Number
Date
(Riparian Property Owner Information)
Signature
Print or Type Name
Mailing Address
City/StatelZip
Telephone Number
Date

RECEIVED
Authorized Agent Consent Agreement JAN 2 6 2012.
DCM-MHD CITY
I k 1 r I CIS M i 106,1( _, hereby authorize � �5 (D �'1C(r I Ylc (L rz+, to act on
(Property Owner)
(Authorized Agent)
my behalf in obtaining CANIA permits for the location listed below. This agency
authorization is limited to the specific activities described above.
Property Address:
Property Owner's Mailing Address and Phone Number:
VC) -oy,5` 01 C)
6 1 r micq �nm_, A L 5
Property Owner's Signature:
Authorized Agent Signature:
Date: :TA'-v 2 4 / 1 2o! 2.
Form: Authorized Agent Agreement as developed by NCDCM revised 7/29109