84-024_Wallace, John C._19840326 (2)

GENERAL INFORMATION RECEIVED
,-ffLAI`46-OWNER �?f' 2 184
Name .SOH1v L[ A fF_ CWv • �c
Address
City ��s 1iO� State /�! L� . Zip 27 9.f `/ Phone
/I
2. AUTHORIZED AGENT
Name
Address
City State Zip Phone
3. LOCATION/DESCRIPTION OF PROJECT
r t✓ 5 tf 5 et a.r O T en F r C— c. pfT
r �ir7"sC- J
4. AREAS OF ENVIRONMENTAL CONCERN (AEC) CLASSIFICATION
(To be filled in by Local Permit Officer prior to completing application.)
j�Ocean Hazard Estuarine Shoreline Other
5. PROPOSED USE
Residential Commerical/Industrial Other
6. SIZE OF BUILDING IN SQUARE FEET: N�
r-7. SIZE OF SITE IN SQUARE FEET: — — - - - - -
- This application includes: 'general information (this ,This the day of
form), a site drawing as described on the back of this
_._ application, the ownership statement, the AEC hazard `V
notice where necessary, a check for $25.00 made payable
to the locality, and any information as may be pro-
` vided orally by the applicant. The details of the applica- . Ap&nt's signature (or authorized agent)
tion as described by' these sources are %incorporated
without reference in any permit which may be issued. Indicate below address and phone if not shown above. -
Deviation from these details will constitute a violation
of any permit. Any person developing in an AEC without
a CAMA permit is subject to civil, criminal and admini-
strative action. 3