39684_RODRIGUEZ, MELVIN_20040831

[J CAMA / ❑ DREDGE & FILL
GENERAL PERMIT Previous permit#
CINew ❑Modification JComplete Reissue ❑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
[] Rules attached.
Applicant Name M* t v' c Pl P' S Project Location: County f"e f i t , ( '
Address `I (' "I rry Street Address/ State Road/ Lot #(s)
City r0" , I J F 1^ State 41 ZIP 09044
Phone # (r c t) `44 c.? & Fax # ( }
Authorized Agent M A
Affected ❑ CW 0 EW P9 PTA ❑ ES ❑ PTS
AEC(s): ❑ OEA ❑ HHF ❑ IH ❑ USA ❑ N/A
❑ PWS: ❑ FC:
ORW: yes / no PNA yes / no Crit. Hab. yes / no
Type of Project/ Activity
i; j Yla;
Pier (dock) length
Platform(s) +
Finger pier(s)
f
Groin length
number - - - - -
I
Bulkhead/ Ripraplength
avg distance offshore
ZIP /i'A
Phone # () River Basin 'I' #V
Adj. Wtr. Body ,'c ' ` 6 .F k ^(nat /man /unkn)
Closest Mal. Wtr. Body (c,,F
Subdivision try l & .t ( P' r fc r'c
City
max distance offshore %" c
Basin, channel
I
(Scale: /kW )
cubic yards
L
iG f 1 / i� f I' + , ?
Boat ramp
=d?r C,
Boathouse/ Boatlift '
I
-C Y^.�f'►rc
'
L(`14�r1f 3 i3'+ 3'
Beach Bulldozing
Other r,o "f r "7
Shoreline Length
SAM not sure yes , io
---
-- -^--- — .�
Sandbags: not sure yes now
i 1 is�o a
Moratorium: n/a yes Q
Photos: yes io
t
(,t
Waiver Attached: yes A
9---
----!---
-
A building permit may be required by:
n a t. F It ,
❑ See note on back regarding River Basin rules.
Notes/ Special Conditions
1
r^c•' /.
) 1
_IP�a cft-.tt fG �!/ (1` �I � C'!'71�f.
Ot
Agent or Applicant Printed Name j
Signature Please read compliance statement on back of permit
Application Fee(s) Check #
Permit Officer's Signature
�(, 3f V y
Issuing Date
Expiration Date
/c, a(lt J J+.
)0r"3c 19A
Local Planning Jurisdiction
Rover File Name

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, certifythat 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 (910-395-3900) for more information on how to comply with thesebuffer rules.
Division of Coastal Management Offices
Central Office Elizabeth City District
Mailing Address: 1367 U.S. 17 South
1638 Mail Service Center Elizabeth City, NC 27909
Raleigh, NC 27699-1638 252-264-3901
Location:
Parker -Lincoln Building
2728 Capital Blvd.
Raleigh, NC 27604
919-733-2293 / 1-888ARCOAST
Fax: [phone]
Fax: [phone]
(Serves: Camden, Chowan, Currituck,
Dare, Gates, Pasquotank and Perquimans
Counties)
Morehead City District
151-B Hwy. 24
Hestron Plaza 11
Morehead City, NC 28557
202-808-2808
Fax: [phone]
(Serves: Carteret, Craven, Onslow -above
New River Inlet- and Pamlico 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
910-395-3900
Fax: [phone]
(Serves: Brunswick, New Hanover,
Onslow -below New River Inlet- and
Pender Counties)
www.nccoastalmanagement.net
Revised 10/05/01

i uc PKUNIOF THE DOCUMENT HA, .... ___.._ _... ..—,, ,, .. ,. ,... .. uHAvvcn "".'•.."'. .....'.
A MICRO -PRINT DAM UNE AND P.O. BOX 9476, MINNEAPOLIS, MN 55480 FtiATUKEJ WILL INDICATE A C'OI'1'�
TravelersExpress.
7-
DATE Ty
74-160 67379
7 19 w
9,9 uj
cam.
PAY TO THE
ORDER OR
l'
W
! PURCHASER, BY SIGNING YOU AGREE TO THE SERVICE CHARGE AND
OTHER TERMS ON THE REVERSE SIDF.
IMPORTANT -SEE BACK BEFORE
.A HIND
,-
...
PURCHASER, SIGNER FOR DRAWER
�`4� ��='r::Jri:
)"j''•: :'jr:: >�:: at :It: ir:: 'at i:�: :dr:: :ir:::.I�._
;
':"• 0
i r �
RCHASER'S ADDRESS
Payable Thru ` NOT
S\CAYF
� m �'-t
.. _ ..,
:, I.. W
WF National Bank South Central GOOD
E
o ..I.
r �� { �.-._..:.:+
,•.
'::�•: (:':.1 {: �_{ I { ' :
t; j
-
z
Faribault, MN OVER
1:091900S331:774 7606737 2115
-
90
_

WATERWAY
i
INTRACOASTAL
79.09
78.93
N06°5h'07"W
158 98
ClarkProperty
76.07
M. Rodriquez
� 3
O
CO GABE LLC m
Property
2
O
o Property N
(�
UFS LLC I
169.26
156.14
�---- 153.57
Property
_ ---�
I
o
1
N01 °D5'05"W
INOD°20'35"E
161.99
EXISTING DRAINAGE
CULVERT
Sight Plan
Rodriguez Property
Lot #2 Block C -,
I
I
Sea Gate
Beaufort Township
I
I
Notes: 0 1
39
IProposed
6'x65' max. access to a "T"
running with gazebo and two uncovered boat lifts
I
� �
I
1
on either side of the proposed plat form

m
VACANT LOT OFFER TO PURCHASE AND CONTRACT
NOTE: This contract is intended for use only for lots which have been developed pursuant to a Subdivision Ordinance adopted by a
City or County and for which a plat has been recorded in the Office of the Register of Deeds in the county in which the property+ is
located. If Seller is Buyer's builder and the sale involves the construction of a new single family dwelling prior to closing, use the
standard Offer to Purchase and Contract (Form 2) with the New Construction Addendum (Form 2A3).
in LA i oar : a _e� _ _ as Buyer,
hereby offers to purchase a� � -- as Sella'
upon acceptance of said offer, agrees to sell a d convey, all of that plot, piece or parcel of land described below (hereafter referred to
as the "Property"), upon the following terms and conditions:
1. REAL PROPERTY: Located in the City of �,,,.�,' �A- County of
State of North Carolina, being known as and more particularly described as:
Street Address Zap
Subdivision Name �t -Jr-B 'w-k. C-
as shown on
Plat Reference: Lot ? _ , Block or Section IL
Plat Book or Slide . _— _ at Page(s) _(Property acquired by Seller in Deed Book at
Page )
NOTE: Prior to signing this Vacant Lot Offer to Purchase and Contract, Buyer is advised to review Restrictive Covenants, if any,
which may limit the use of the Property, and to read the Declaration of Restrictive Covenants, By -Laws, Articles of Incorporation,
Rules and Regulations, and other governing documents of the owners' association and/or the subdivision, if applicable.
2. PURCHASEPRICE: The purchase price is S / , Q12Q- and shall be paid
as follows: ``I'
(a) S d, p®p . � O personal check
_, EARNEST MONEY DEPOSIT with this offer by J cash
0 bank check ID certified check EJ other: to be deposited
and held in escrow by 14,E W*rd ee ekr1d Co. -rfv s l- ecov►1 } ("Escrow Agent") until the sale is
closed, at which time it will be credited to Buyer, or until this contract is otherwise terminated. In the event: (1) this offer is not
accepted; or (2) any of the conditions hereto are not satisfied, they all earnest monies shalt be returned to Buyer. In the event of
breach of this contract by Seller, upon Buyer's request, all earnest monies shall be returned to Buyer, but such return shall not
affect any other remedies available to Buyer for such breach. In the event this offer is accepted and Buyer breaches this contract,
then ail earnest monies shall be forfeited upon Seller's .request, but receipt of such forfeited earnest monies shall not affect any
other remedies available to Seller for such breach.
NOTE: In the event of a dispute between Seller and Buyer over the return or forfeiture of earnest money held in escrow by a
broker, the broker is required by state law to retain said earnest money in the broker's trust or escrow account until a written
release from die parties consenting to its disposition has been obtained or until dis4ursement is ordered by a court of competent
jurisdiction.
(b) S 4 206. ADDITIONAL EARNEST MONEY DEPOSIT to be paid to Escrow Agent no later than
, TIME BEING OF THE ESSENCE WITH REGARD TO SAID DATE.
(c) S _, By ASSUMPTION of the unpaid principal balance and all obligations of Seller on the existing loan(s)
secured by a deed of trust on the Property in accordance with the attached Loan Assumption Addendum.
(d) S , BY SELLER FINANCING in accordance with the attached Seller Financing Addendum.
(e) S -760CX7 09—_, BALANCE of the purchase price in cash at Closing.
3. CONDITIONS: (State N/A in cac blank that is not a condition to this contract.)
(a) Buyer must be able to obtain a 3 Conventional O Other. _ loan at a 0 Fixed Rate 0 Adjustable
Rate in the principal amount of 7(, a p a* for a term of _^� year(s), at an initial interest rate not
to exceed - V % per annum, with rnorigage loan discount points not to exceed [Z_ % of the loan amount. Buyer shall
apply for sat loan wi(hin -:,50 days of the Effective Date of this contract. er shall use Buyer's best efforts to secure the
lender's customary loan commitment letter on or before ZQGV and to satisfy ail terms and
conditions of the loan commitment letter by Closing. After the above 494* date, Seller may request in writing from Buyer a copy
Pagel of 4
Phis form jointly approved by: STANDARD FORM 12 - T
® North Carolina Beocr=dn
datior, 0 7/2003
RfAaOR� North Caroli of REALTORS®,Inc.Buyer Initial Seller Initials

of the loan commitment fetter. if Buyer fails to provide Seller a copy of the loan commitment letter or a written waiver of this
Wan condition within five days of receipt of Seller's request, Seller may terminate this contract by written notice to Buyer at any
time thereafter, provided Seller has not then received a copy of the letter or the waiver.
(b) There trust be no restriction, easement, zoning or other governmental regulation that wouid prevent the reasonable use of the
Property for Qa�r �aek� purposes ("intended Use").
(e) The Property must be in substantially the same or better condition at Closing as on the date of this offer, reasonable wear and tear
excepted.
(d) All deeds of trust, liens and other charges against the Property, not assumed by Buyer, must be paid and satisfied by Seller prior
to or at Closing such that cancellation may be promptly obtained following Closing. Seller shall remain obligated to obtain any
such cancellations following Closing.ee simple
(e) Title must be delivered at Closing by GENERAL WAR3tANTY DEED unless otherwise statedretrorared t}rroun, and must bh the dace of
marketable and insurable title, free of all encumbrances except: ad valorem taxes for the current year (prorated g
Closing); utility casements and unviolated restrictive covenants that do not materially affect the value of the Property; and such
other emisribrances as may be assumed or specifically approved by Buyer. The Property must have legal access to a public right
of way.
4. SPECIAL ASSESSMENTS: Seller warrants that there are no pending or confirmed governmental special assessments for
sidewalk, paving, water, sewer, or other improvements on or adjoining the Property, and no pending or confirmed owners' association
special assessments, except as follows: _K& ,t
(Insert ":None' or the identification of such assessments, if any.) Seller shall pay all owners' association assessments and all
governmental assessments confirmed through the time of Closing, if any, and Buyer shall take title subject to all pending assessments,
if any, unkaa otherwise agreed as follows: Mort e _
S. PRORATIONS AND ADJUSTMENTS: Unless otherwise provided, the following items shall be prorated and either adjusted
between the parties or paid at Closing: (a) Ad valorem taxes on real property shall be prorated on a calendar year basis through the
date of Closing; (b) All late listing penalties, if any, shall he paid by Seller, (c) Rents, if any, for the Property shall be prorated through
the date of Closing; (d) Owners' association dues and other like charges shall be prorated through the date of Closing. Seller
represents that the regular owners' association dues, if any, arc S —""-' per G dtFsf at:>wej .
d. CLOSING EXPENSES: Buyer shall be responsible for all costs with respect to any loan obtained by Buyer. Buyer shall pay for
recording the deed and for preparation and recording of all instruments required to secure the balance of the purchase price unpaid at
Closing. Seller shall pay for preparation of a deed and all other documents necessary to perform Seller's obligations under this
agreement, and for excise tax (revenue stamps) required by law. if Seller is to pay any of Buyer's expenses associated with the
purchase of the Property, the amount thereof shall be S Mover excluding any portion disapproved by Buyer's
knder.
7. EVIDENCE OF TITLE: Seller agrees to use his best efforts to deliver to Buyer as soon as reasonably possible after the Effective
Date of this contract, copies of all title information in possession of or available to Sell.9r, including but not limited to: title insurance
policies, attomey's opinions on title, surveys, covenants, deeds, notes and deeds of trust and easements relating to the Property. Seller
authorizes (1) any attorney presently or previously representing Seller to .release and disclose any title insurance policy in such
attorney's file to Buyer and both Buyers and Seller's agents and attorneys; and (2) the Property's title insurer or its agent to release and
disclose all materials in the Property's title insurer's (or title insurers agent's) file to Buyer and both Buyer's and Seller's agents and
attorneys.
_. LABOR AND MATERIAL: Seller shall furnish at Closing an affidavit and indemnification agreement in form satisfactory to
Buyer showing that all labor and materials, if any, fumished to the Property within 120 days prior to the date of Closing have been
paid for and agreeing to indemnify Bayer against all loss from any cause or claim arising therefrom.
9. CLOSING: Closing shall be defined as the date and time of recording of the deed. All parties agree to execute an and. all
documents and papers necessary in connection with Closing and transfer of title or, or before A4 ♦Irn�a�t`l�si�.%*o
at a place designated by Buyer. The deed is to be made to
CLOSING SHALT. CONSTITUTE CC TAIVCEQF THE PROPERTY IN ITS THEN EXdSTING CONDITION UNLESS lrolldt'
P>ROVISISIN IS OTHERWISE MADE IN WRITING.
10. POSSESSION: Unless otherwise provided herein, possession shall be delivered at Closing. No alterations, excavations, tree
remevai or other such ac.ivities may be done before possession is delivered.
Page 2 of 4
STANDARD FORM 12 - T
Buyer Initial Seller Initials 0712003

11. SEWER SYSTEM (check only ONE):
O Buyer has investigated the costs and expenses to install the sewer systemapprovedby the Improvement Permit attached hereto as
Exhibit A and hereby approves and accepts said Improvement Permit.
U Seller represents that the system has been installed, which representation survives Closing, but makes no further representations as
to the system. Buyer acknowledges receipt of the Improvement Permit attached hereto as Exhibit A. Buyer shall have the option of
inspecting or obtaining, at Buyer's expense, inspection(s) to determine the condition of the system. If the system is not performing the
function for which intended and is in need of immediate repair, Buyer may terminate this Contract and the Earnest Money Deposit
shall be refunded to Buyer. Buyer waives this condition unless Buyer provides written notice to Seiler by
that this condition cannot be satisfied, time being of the essence.
D This contract is contingent upon Buyer obtaining an Improvement Permit or written evaluation from the County Health Department
("County") for a (check only ONE) O conventional or O other
ground
absorption sewage system for a --bedroom home. All costs and expenses of obtaining such Permit or written evaluation shall
be borne by Buyer, except Seller, by no later than -- , shall be responsible for clearing that portion of the
Property required by the County to perform its tests and/or inspections. Buyer shall use Buyer's best efforts to obtain such Permit or
written evaluation. if the ground absorption sewage system is not allowed, Buyer may terminate this contract and the Earnest Money
Deposit shall be refunded to Bayer. Buyer waives this condition unless Buyer provides written notice to Seller by
that this condition cannot be satisfied, time being of the essence.
❑ Buyer has investigated and approved the availability, costs and expenses to connect to a O public or ❑ community sewer system.
12. SOIL, WATER. UTILITIES AND ENVIRONMENTAL CONTINGENCY: This contract is contingent upon Buyer obtaining
report(s) that (i) the soil is suitable for Buyer's Intended Use, 00 utilities and water are available to the Property, (iii) there is no
environmental contamination, law, rule or regulation that prohibits, restricts or limits Buyer's Intended Use, and (iv) there is no flood
hazard that prohibits, restricts or limits Buyer's Intended Use (collectively the "Reports'). All costs and expenses of obtaining the
Reports shall be borne by Buyer. Buyer shall use Buyer's best efforts to obtain such Reports. if the Reports cannot be obtained, Buyer
may terminate this contract and the Earnest Money Deposit shall be refunded to Buyer. Buyer waives this condition unless Buyer
provides written notice to Seller by that this condition cannot be satisfied, time being of
the essence.
13. RIGHT OF ENTRY, RESTORATION AND INDEMNITY: Buyer and Buyer's agents and contractors shall have the right to enter
upon the Property for the purpose of appraising the Property, and performing the tests and inspections permitted in Sections 11, 12 and 13
of this contract. If Buyer terminates this contract as provided herein, Buyer shall, at Buyer's expense, restore the Property to substantially its
pre -entry condition within thirty days of contract termination. Buyer will indemnify and hold Seller harmless fmm all ioss, damage, claims,
suits or costs, which shall arise out of any contract, agreement, or injury to any person or property as a result of any activities of Buyer and
Buyer's agents and contractors relating to the Property. This indemnity shall sur✓lye this contract and any termination hereof.
Notwit WAnding the foregoing, Seller shall be responsible for any loss, damage, claim, suif or cost arising out of pre-existing conditions of
the Property and/or out of Seller's negligence or willful acts or omissions.
14. OTHER PROVISIONS AND CONDITIONS: (ITEMIZE ALL ADDENDA TO THiS CONTRACT AND ATTACH
HERETO.)' he ?%wck&St aP 44%11 1e4 is Suts5tat 4% 4kt, +arm i "ci Cowj''o yr S o4 4-4 �ttsrvo�.'art
n�srttt�sarnl* 4o' io4''fA*\*Pk04t.'t. 54-o v%kem i_..,1:r�'. IP bwye/ sleeks N04' +• ' 1%00'c +wt4, !of OW
S;;%w6y% rLAA.AdMq Ptah 44S CoK}<ae,l beGames rive! and, Yold.
IS. RISK OF LOSS: The risk of loss or damage by fire or other casualty prior to Closing shall be upon Seller.
16. ASSIGNMENTS: This contract may not be assigned without the written consent of all parties, but if assigned by agreement, then
this contract shall be binding on the assignee and his heirs and successors.
17. PARTIES: This contract shall be binding upon and shall inure to the benefit of the parties, i,e., Buyer and Seller and their heirs,
successors and assigns. As used herein, words in the singular include the plural and the masculine includes the feminine and neuter
genders, as appropriate.
18. SURVIVAL: If any provision herein contained which by its natlare and effect is required to be observed, kept or performed after
the Closing, it shalt survive the Closing and remain binding upon and for the benefit of the parties hereto until fully observed, kept or
performed.
14. ENTIRE AGREEMENT: This contract contains the entire agreement of the parties and there are no representations, inducements
or other provisions other than those expressed herein.. All changes, additions or deletions hereto must be in writing and signed by all
parties. Nothing contained herein shall alter any agreement between a REALTOR" or broker and Seiler or Buyer as contained in any
listing agreement, buyer agency agreement, or any other agency agreement between them.
Page 3 of 4
STANDARD FORM 12 - T
Buyer Initials_ Seller Initials V 7/2003

20. INOTbCE'AND EXECUTION: Any notice or communication to be given to a party herein may be given to the party or to such
party'c agent. This offer shall become a binding contract (the "Effective Date") when signed by both Buyer and Seller and such
signing is communicated to the offering party. This contract is executed under seat in signed multiple originals, all of which together
conadcute one and the same instrument, with a signed original being retained by each party and each REALTORO' or broker hereto,
and the parties adopt the word "SEAL" beside their signatures below.
Buyer acknowledges having made an on -site personal examination of the Property prior to the making of this offer.
THE NORTH CAROLINA ASSOCIATION OF REALTORM INC. AND THE NORTH CAROLINA BAR ASSOCIATION
MAKE NO REPRESENTATION AS TO THE LEGAL VALIDITY OR ADEQUACY OF ANY PROVISION OF THIS FORM IN
ANY SPECIFIC TRANSACTION. IF YOU DO NOT UNDERSTAND THIS FORM OR FEEL THAT IT DOES NOT PROVIDE
FOR YOUR LEGAL NEEDS, YOU SHOULD CONSULT A NORTH CAROLINA REAL ESTATE ATTORNEY BEFORE YOU
SIGN IT.
Date:
Buyer — L)
Bate: — --- ----
Date:��wr
Seller
Date:
Buyer 4 (SEAL) Seller (SEAL)
Escrow Agent acknowledges receipt of the earnest money and agrees to hold and disburse the same in accordance with the
terms hereof. q �,
Date c7 S Z� 2 ` 1 — Firm:--
Selling Agent/Firm/Phone,
Listing Agent/Firm/Phone
(Signature)
Acting as O Buyer's Agent 0 Seller's (sub)Agent O Dual Agent
Acting as 0 Seller's (sub)Agent O Dual Agent
Page 4 of 4
a
STANDARD FORM 12 — T
O 7/2003

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FORA PIERIMOORING PILING.S/BOATLIFT/BOATHOU.SE)
I hereby Certify that I own property adjacent toA�Yr�1 +S0�riau�z 's
(Name of Property Owner)
property located at 4o4- # 7— Sea. (qk --w
on �'nira Cr1ul Li/a,�Cr ,in ,N.C.
(Waterbody) I (Town and/or County)
He has described to me, as shown below, the development he is proposing at that location, and, I
have no objections tom his proposal. I understand that a pier/mooring pilings/boatlift/boathouse
must be set back a minimum distance of fifteen feet (15) from my area of riparian access unless
waived by me.
—Z I do not wish to waive the setback requirement.
I do wish to waive the setback requirement.
--------------------------------------------------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(TO BE FILLED IN BYINDIVIDUAL PROPOSING DEVELOPMEN7�
Signature
Ark, s NWee Cke.,O
Print or Type Name GA t- Li-c-
20
Telephone Number
Date: ���Z�y

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIERIMOORING PILINGSIBOATLIFTIBOATIIOUSE)
I hereby Certify that I own property adjacent to lYIdv odr; I U e.-1— 's
(Name of Prop rty Owner)
property located at Sea ms �loc% , t—of --d- 7 ,
(Lot, Block, Road, etc..)
N.C.
(Waterbody) / (Town and/or County)
He has described to me, as shown below, the development he is proposing at that location, and, I
have no objections tom his proposal. I understand that a pier/mooring pilings/boatlift/boathouse
must be set back a minimum distance of fifteen feet (15) from my area of riparian access unless
waived by me.
V I do not wish to waive the setback requirement.
I do wish to waive the setback requirement.
--------------------------------------------------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(TO BE FILLED IN BYINDIVIDUAL PROPOSING DEVELOPMENT)
I l 7n04
f
� ��
[Vic), �.>a . dye y 'Aa
Signature
Te.Cq- a
Print or T pe Name
223 - Z77%
Telephone Number
Date: "n