097-89_Porker, William F._19891205

/
GENERAL INFORMATION
1. LANDOWNER
Name w Ml
EEC p 5 19a9
Address �D)Nev",,
Y
Cit S�/►S lrr .C. State Zip.StSLLLl_l_ Phone U6
2. AUTHORIZED AGENT
Name
Address 15L j' oy I �A�n Dr
City cJici+aV f Gv �� State (� L. Zip 21 S Phone Si % • 3 6 3 T
3. LOCATION/DESCRIPTION OF PROJECT
4. AREAS OF ENVIRONMENTAL CONCERN (AEC) CLASSIFICATION
(To be filled in by Local Per it Officer prior to completing application.)
Ocean Hazard Estuarine Shoreline Other
5. PROPOSED USE
Residential Commerical/Industrial Other
6. SIZE OF BUILDING IN SQUARE FEET: 151 X ��
7. SIZE OF SITE IN SQUARE FEET:
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 $25.00 made payable
to the locality, and any information as may be pro-
vided orally by the applicant. The details of the applica-
tion as described by these sources are incorporated
without reference in any permit which may be issued.
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.
OTHER PERMITS MAY BE REQUIRED...
The activity which you are planning may require permits
other than the CAMA minor permit you are applying for
here. As a service we have compiled a listing of the kinds
of permits which might be required. We suggest that you
check over this list with your Local Permit Officer to
determine which, if any, of these may apply to your
project. This is not a requirement of CAMA, only a sugges-
tion to help you complete your project as quickly as
possible.
v
This the ( day of Der-
1 9J?_7..
Applicant's s' azure (or aut orized agent)
Indicate below address and phone if not shown above.
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, Others:
LOCALITY w • PERMIT NUMBER 0 q ?-"0 `7

STATEMENT OF OWNERSHIP
I, the undersigned, an applicant for a CAMA minor development permit, being either the owner of property in
an area of environmental concern 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 follows: (check one)
an owner of record title, Title is vested in--a����
see Deed Book 12—t-u--, page in the
County Registry of Deeds.
an owner by virtue of inheritance. Applicant is an heir to the estate of
probate was in County.
if other interest, such as written contract or lease, explain below or use a separate sheet
attached 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)
(2) T,,,_..
S►n� � �.
I Z LerLcvrit
(�cX SwatisbcNo
(3)
(4)
FOR DEVELOPERS IN OCEAN HAZARD AND ESTUARINE SHORELINE EROSION AREAS:
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 flood -proofing 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 the —day of DeC , 194—
Land owne o person aut rized to act as his agent
for. purposes of filing a CA A application.