04-634_Brownlee, David_20040407

I : This permit action.may be appealed;by the permittse or oil
qualified. persons within twenty 00). days of the issuing date.
From:the dateof.anappeal; any wotk-rmh6cied under this Pe
(m m..si cease until,the appeai.is resolved: .
permit must be on the project site and accessible to tl
permit<6ff6r:when the project is inspected for cam
pHance: .
Any rnaintanance work orprojea-modifications"notcovere
undo' *Hhis: perinit: requires.further written permit approval..
All work must :aease.when :this perrrsit expires on Decembc
st, .
In issuing this permit it is.agreed-that.this project is consist
With the bcaf l=and Use Plan: and all applicable.ordinances.
This permft may :not be transferred tc:angthir party wfthou
pp the writtemaroval-61"the Mlsian of: Goastal'Management.

T0,`:'d Gi E.PiiLi.n;LD !SLE
-ocality _
"'ENERAL INFORMATION
;..AND OWNER
flame a v,
Address 1(�
Permit Number r
JUL 2 3 2004
erehead City D
city State / ?' Z,— Zip Z -7; l 1 Phone
AUTHORIZED AGENT
Name
Address
City State Zip Phone
LOCATION OF PROJECT 3,0 Z
�Hl l CG, ARC -
(If not oceanfront, is waterbody natural or manmade?) DESCRIPTION OF PROJECT f-,054 494/ '03
?VIP / Gn 0�1
AREAS OF ENVIRONMENTAL CONCERN (AEC) CLASSIFICATION
(To be filled in by the Local Permit Officer prior to completing application.)
Ocean Hazard Estuarine Shoreline ORW Shoreline Public Trust Shoreline Other
PROPOSED USE
Residential Commerical/Industrial Other
SQUARE FOOTAGE OF BUILDING FOOTPRINT AND OTHER IMPERVIOUS OR
BUILT -UPON SURFACES (such as driveways, etc.) within 75 feet of the estuarine shoreline, or 575 feet of an
ORW shoreline, or 30 feet of the public trust shoreline.
SQUARE FOOTAGE OF TOTAL FLOOR AREA OF BUILDING v ��
SQUARE FOOTAGE OF SITE
OTHER PERMITS MAY BE REQUIRED:
The activity you are planning may require
permits other than the CAMA minor
development permit. As a service we have
compiled a listing of the kinds of permits that
might be required. We suggest you check
over the list with your LPO to determine if
any of these apply to your project.
Zoning, Drinking Water Well, Septic Tank
(or other sanitary waste treatment system),
Burning, Electrical, Plumbing, Heating and
Air Conditioning, Insulation and Energy
Conservation, FIA Certification, Sand Dune,
Sediment Control, Subdivision Approval,
Mobile Home Park Approval, Highway
Connection, and others.

STATEMENT OF OWNERSHIP
I, the undersigned, an applicant for a CAMA minor development permit, being either the owner of property in
an AEC or a person authorized to act as an agent for purposes of applying for a CAMA minor development
permit, certify that the person listed as landowner on this application has a significant interest in the real
property described therein. This interest can be described as: (check one)
an owner or record title, Title is vested in see Deed Book ,
page in the County Registry o Dee s.
an owner by virtue of inheritance. Applicant is an heir to the estate of
probate was in County.
if other interest, such as written contact or lease, explain below or use a separate sheet and attach to this
application.
NOTIFICATION OF ADJACENT PROPERTY OWNERS
I furthermore certify that the following persons are owners of properties adjoining this property. I affirm that I
have given ACTUAL NOTICE to each of them concerning my intent to develop this property and to apply for
a CAMA permit.
(Name) (Address)
(1)
(2)
(3)
(4)
zfsSs
FOR DEVELOPERS IN OCEAN HAZARD AND ESTUARINE HAZARD AREAS:
I acknowledge that the land owner is aware that the proposed development is planned for an area which may
be susceptible to erosion and/or flooding. I acknowledge that the local permit officer has explained to me the
particular hazard problems associated with this lot. This explanation was accompanied by recommendations
concerning stabilization and floodproofing techniques.
PERMISSION TO ENTER ON LAND
I furthermore certify that I am authorized to grant and do in fact grant permission to the local permit officer
and his agents to enter on the aforementioned lands in connection with evaluating information related to this
permit application.
This application includes: general information (this form), a site drawing as described on the back of this application,
the ownership statement, the AEC hazard notice where necessary, a check for $100.00 made payable to the locality,
and any information as may be provided orally by the applicant. The details of the application as described by these
sources are incorporated without reference in any permit which may be issue eviction from these details will
constitute a violation of any. permit. Any person developing in an AEC wit o permit is subject to civil, criminal
and administr tive action.
This the day of� 20 , ,/
Land owne?-dr person author' ed to act
for purposes of filing a CAMA ple=T al
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