25-03_Smith, James A_20030827

°4
`1VORTH CAROLINA
FEI�111'
Morehead City CM
t

s5uLc-"�
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Michael F. Easley, Govemor Charles S. ,tortes,` Director William G: Ross Jr., Secretary
August 14, 2006
James A Smith
P O Box 2131
Reidsville, NC 27323 . .
Dear Sir_
The enclosed permit constitutes authorization under the Coastal- Area Management Act, and where applicable, the
State Dredge_ and Fill Law, for.you to proceed` with your project proposal. Please sign bath the original (buff -
colored form) and the copy. Return the copy to this office in the enclosed envelope. Signing the permit and
proceeding means you have waived your right of appeal described below. Please retain the original (buff -colored
form), as it must be available on, site when the project is inspected for compliance.
If you object to' the permit or any of the conditions, you may request a hearing pursuant to NCGS 113A-
121.1 ors 113-229. Your petition for a hearing must be filed in accordance with.NCGS Chapter 150B.with the Office
of Administrative Hearings, 6714 Mail Service: Center,'.Raleigh, 14C • 27611-6714, [phone] within twenty
(20) days of this decisien !on your permifalso be ' aware -that: if another qualified patty 'submits a'valid
objection to the issuance of. this permit within twenty (20) days, "the matter `must be resolved prior to work initiation.
The Coastui;�esorirces Cormitission males the final decision on a� appeal.
The protect plan is subject to those conditions appearing on the permit form. Otherwise, all work must be
I
arried out in accordance with your application. Modifications, time extensions, and future maintenance require
additional approval.- Please read: your permit carefully prior to starting work and review all project plans, as
approved. If you are having the work done by a contractor, it is to your benefit to be sure that he fully understands
all permit requirements.
From time to time, Department personnel will visit the project site. To facilitate this review, we request that .
you complete and mail the enclosed Notice Card just prior to work. initiation. However, if questions arise
concerning permit conditions, environmental safeguards, or problem areas, you may contact Department personnel
at any time for., assistance. By working in accordance with the permit,, you will be helping to protect our vitally
important coasts resources.
Sincerely,
Douglas V. Huggett/lsb
_ Major Permits and. Consistency Manager
Enclosure
400 Commerce Avenue, Morehead City, N.C. 28557
Phone: [phone] FAX: .[phone] Internet: hfp://dcm2.enr.state.nc.us
An Equal opportunity 1 Affirmative Action Employer— 50% Recycled 110% Post Consumer Paper

DCM-MHD 425-03 RENEWAL
Local Government Permit Number
CAMA
MINOR DEVELOPMENT
PERMIT
^�
As authorized by the State of North Carolina, Department of Environment,
and Natural Resources and, the Coastal Resources Commission for development.
in an area of environment concern pursuant to Section 113A418 of the
t General Statutes, "Coastal Area Management"
Issued to Mr. lames A.'Smith, authorizing development in the COASTAL SHORELINE.(AEC) at.680 Smith Farm '
Road outside Havelock. Craven County, as requested in the permittee's letter, dated 112/12/06. This permit,
issued'on 1 /24/07, is subject to compliance with the application and site drawing (where consistent with the '
permit), all applicable regulations and'special conditions and notes set forth below. Ariy violation of these
terms may subject permittee*to a fine, imprisonment or civil action, or may cause the permit to be null and
void.
This permit authorizes shoreline stabilization above all marsh and the. normal water level. Any.other
development will require additional permits or a modification of this permit. The following conditions
shall apply:
(1) All proposed development and associated construction must be done in accordance with the
application dated 8/14/03, renewal request dated 12/12/06, and workplat drawing(s) dated 8/5/03.
(2) All construction must conform to the N.C. Building Code requirements and all other Local, State and
Federal regulations.
(3) Any change or changes in the plans for development, construction, or land use activities will require a
re-evaluation and modification of this permit.
(4) Prior to initiating and land -disturbing activities, adequate sedimentation/erosion control measures must
be. employed to prevent the movement of unconsolidated materials into the marsh or water., These
measures will remain in place until such time as the area has been properly stabilized with a vegetated
cover.
This permit action may be appealed by the permittee or other
qualified persons within twenty (20) days of the issuing date. From
the date of an appeal, any work conducted under this permit must
cease until the appeal is resolved.
This permit must be on the project site and accessible to the permit
officer when the project is inspected for compliance.
Any maintenance work or project modification not covered under
this permit, require further written permit approval.
AII work must cease when this permit expires on
December31, 2008
In issuing this permit it is agreed that this project is consistent with
the local Land Use Plan and all applicable ordinances.
This permit may not be transferred to another party without the
written approval of the Division of Coastal Management.
DCM Field Representative
Permittee

0
(5) Pursuant to 15 NCAC, Subchapter 7J.0406(b), this permit may not be assigned; transferred, sold or
otherwise disposed of to a third -party by the applicant, agent, or any entity other than the NC Division
of Coastal Management.
(6) It is noted that coastal marsh.exists on the property, and that the proposed development. addressed on
the submitted plat dated 10/14/03. is not located within this marsh.
.(7) No excavation of filling of any wetlands or waters is authorized under this permit. .
(8) Any. development or'land disturbing activity, that is. considered non -water dependent is, not authorized
within 50 feet of the normal high/normal water level unless specifically exempted by Environmental
Management Commission (EMC) Neuse River buffer regulations in place at the time of such
development.
(9) The LAMA alignment staked 7/29/03 is valid for 90 days. After this 90 days period the alignment
will need to be re -staked before contractor commences.
(10) The authorized walkway to the base of the shoreline stabilization should be slatted and drip through
and not exceed 6 feet in width.
(11) A'copy of this permit shall be available onsite for regulatory inspection.
Signature
Date

;0 DCNI=MHD APR 9 2007 #25-03 RENEWAL
Local Govern nt Permit Number
�ioreheaq
City DC1 CAMA-
MINOR DEVELOPMENT
. PERMIT
as authorized by the State of North Carolina, Department of Environment,
and Natural Resources and.the Coastal Resources Commission for development
in an area of environment concern pursuant to Section 113A-118 of the
General Statutes, "CoastaE Area Management"
1'ssued to Mr. larnes-A. Smith, authorizing development in the COASTAL SHORELINE (AEC) at.680 Smith Farm '
Road outside Havelock. Craven County, as requested in the permittee's letter, dated 12/12/06. This permit,
issued on 1 /24/07, is subject to compliance with the application and site drawing (where consistent with the
permit), ail applicable regulations°and ,special conditions and notes set forth. below. Ary violation of these
terms may subject permittee to a fine, imprisonment or civil action, or may cause the permit to be null and
void.
This permit authorizes shoreline stabilization above all marsh and the.normal water level. Any other
development will require additional permits or a' modification of this permit. The following conditions
shall apply:
(1) All proposed development and associated' construction must be done in accordance. with the
application dated 8/14/03, renewal request dated 12/12/06, and workplat drawing(s) dated 8/5/03.
(2) All construction must conform .to the N.C. Building Code requirements. and all other Local, State and
Federal regulations.
(3) Any change or changes in the plans for development, construction, or land use activities will require a
re-evaluation and modification of this permit.
(4) Prior to initiating and land -disturbing activities, adequate sedimentation/erosion control measures must
be employed to prevent the movement of unconsolidated materials into the marsh or water.. These
measures will remain in place, until such time as the area has been properly stabilized with a vegetated
cover.
This permit action may be appealed by the permittee or other
qualified persons within twenty (20) days of the issuing date. From
the date of an appeal, any work conducted under this permit must
cease until the appeal is resolved.
This permit must be on the project site and accessible to the permit
officer when the project is inspected for compliance.
Any maintenance work or project modification not covered under
this permit, require further written permit approval.
All work must cease when this permit expires on
December 31, 2008
In issuing this permit it is agreed that this project is consistent with
the local Land Use Plan and all applicable ordinances.
This permit may not be transferred to another party without the
written approval of the Division of Coastal Management.
DCM Field Representative
Permittee r

1.
Smash, James A.
Minor Permit # 25-03 Renewal
Page 2`of 2
(5) Pursuant to 15 NCAC, Subchapter 7J.0406(b), this permit may not be assigned, transferred, sold or
.otherwise disposed of to a third -party by the applicant, agent, or any entity other than the NC Division
of Coastaf Management.
(6) ' It is noted that coastal marsh. exists on the property, and that the proposed development addressed on
the submitted plat dated 10/14/03 is not iocated-within this marsh.'
(7) No excavation of filling of any wetlands or waters is authorized under this permit.
(8). Any development or land disturbing activity_that_is considered non -water dependent is not authorized
within 50-feet of the normal high/normal water.level unless specifically exempted by Environmental
Management Commission (EMC) Neuse River buffer regulations in place at the time* of such
development.
(9) . The CAMA alignment staked 7/29/03 is valid for 90 days. After this 90 days period the alignment
will need to be're-staked before contractor commences.
(10) The authorized walkway to the base of the shoreline stabilization should be slatted and drip through
and not exceed 6 feet in width.
(11) A copy of this permit shall be available onsite for regulatory inspection.
Date J
Signature "

DCM/MHD
Local Government
'K'U
#25=03
Permit Number
CAMA
MINOR DEVELOPMENT
PERMIT
as authorized by the State of North Carolina, Department of Environment
and Natural Resources and the Coastal Resources Commission for development
in an area of environmental concern pursuant to Section 113A-118 of the
General Statutes, "Coastal Area Management."
Issued to Mr. James A. Smith authorizing development in the Coastal Shoreline Area
of Environmental Concern at 680 Smith Farm Road outside Havelock, Craven
County as requested in the permittee's application, dated A»gii-r 14. 7nn3
This permit, issued on is subject to compliance with the application and site drawing (where consistent
with the permit), all applicable regulations and special conditions and notes set forth below. Any violation of these terms may subject
permittee to a fine, imprisonment or civil action, or may cause the permit to be null and void.
This Permit authorizes shoreline stabilization above all marsh and the normal water level. Any other
development will require additional permits or a modification of this permit. The following
conditions shall apply:
1. All proposed development and associated construction must be done in accordance_ with the
application dated August-14, 2003, workplat drawing (s) dated August 5, 2003. -
2. All construction must conform to the North Carolina Building Code requirements and all other Local,
State and Federal regulations.
3. Any change or changes in the plans for development, construction, or land use activities will require a re-
evaluation and modification of this permit.
4. Prior to initiating any land -disturbing activities, adequate sedimentation/erosion control measures must
be employed to prevent the movement of unconsolidated materials into the marsh or water. These measures
will remain in place until such time as the area has been properly stabilized with a vegetated cover.
See Page 2 for additional conditions:
This permit action may be appealed by the permittee or other
qualified persons within twenty (20) days of the issuing date.
From the date of an appeal, any work conducted under this per-
mit m„st cease until the appeal is resolved.
This permit must be on the project site and accessible to the
permit officer when the project is inspected for compliance.
Any maintenance work or project modifications not covered
under this permit requires further written permit approval.
All work must cease when this permit expires on December
31, 2006
In issuing this permit it is agreed that this project is consistent
with the local Land Use Plan and all applicable ordinances.
This permit may not be transferred to another party without
the written approval of the Division of Coastal Management.
Local Permit Officer (signature)
Brad Shaver, Coastal Management Rep.
N.C. Division of Coastal Management name
Hestron Plaza II, 151—B Hwy 24
Morehead City, N C 98557
Tele: [phone] address
c
Permittee
ginature required if special conditions kove apply to permit)

Minor Permit #25-03
James A. Smith
Page 2 of 2
5. Pursuant to 15 NCAC, Subchapter 7J.0406(b), this permit may not be assigned,
transferred, sold or otherwise disposed of to a third -party by the applicant, agent, or any
entity other than the NC Division of Coastal Management.
6. It is noted that coastal marsh exists on the property, and that the proposed
development addressed on the submitted plat dated August 5, 2003 is not located within
this marsh.
7. No excavation or filling of any wetlands or waters is authorized under this permit.
8. A copy of this permit shall be available onsite for regulatory inspection.
9. Any development or land disturbing activity that is considered non -water dependent is
not authorized within 50 feet of the normal high/normal water level unless specifically
exempted by Environmental Management Commission (EMC) Neuse River buffer
regulations in place at the time of such development.
10. The CAMA alignment staked on Jul y29, 2003 is valid for 90 days. After this 90 days
period the alignment will need to be re -staked before contractor commences.
11. The rip rap used for shoreline stabilization must be clean and free of debris including
re -bar.
12. The authorized walkway to the base of the shoreline stabilization should be slatted
and drip through and not exceed 6 feet in width.

Zf
, 'AUG Y 4 l2003
APPLICATION
ON FAR
CAIVUM
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I.
?: 'D L NTT
-
MIT
a. -
4
t
9 .
In 1974, the North Carolina General Assembly passed the Coastal Area
,ManagementyAct
and set the stage for guiding development in fragile
and productive areas that border the state's sounds and oceanfront. Along
with requiring special care by those who build and develop the General
Assembly directed theT Coastal Resources Commission (CRC) to imple-
rrY =, �.
merit clear regulations that minimize the burden on the applicant.
This application for a minor development permit under CAMA is part
of the Commission's effort to meet the spirit and intent of the General
` Assembly. If has been designed to be straightforward and require no
p: .�.
more time or effort necessary from the applicant.- Please go over this `
folder with the Local Permit Officer (LPaO) for the locality in which you
t plan to build'to be certain that you understand whatinformation he or
j¢A
nee � LL
she" ds.
Under` CAMA re ations, the ni � � gul nor permit is to be issued within 25 =
A 1
days once a complete application is in hand.' Often less time is needed if
` d `" ` °
lithe, proiect is, simple'. The process generally takes about 18 days. You `
A ' canspeed the approval process bykmaking certain that your application
is complete and signed,,that your drawing meets the specifications given
,.
k
-_ inside and that your application fee is attached.
Other permits are sometimes required for development in the coastal
�' ar
N area. While these are not CAMA-related, we urge you to check with the
Local Permit Officer to determine which of these you may need. A
listing is included on page 2 of this, folder.
r
Al
tA
j, ��
We appreciate your cooperation with the North Carolina Coastal Man-
o
E
agement Program and your willingness to build in away that protects '
'
the; resources of our beautiful and productive coast.
Coastal Resources Commission
Divisionof Coastal Management
fpi
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v
s r

ity Permit Number
Ocean Hazard Estuarine Shoreline ORWrShoreline Public Trust Shoreline' Other
(For official use only)
GENERAL INFORMATION
fAUG 14 2003
LAND OWNER
Name J P n' C 5 A- Sr* " rJ-, r
Address 75 m P! ►rfo -1 rz- Q*
City State N-C Zip A >3a o Phone 331-
-3'P9-i669
8k6 9
AUTHORIZED AGENT
Name J A r--. 0 5. A.'S nr• i 1 k,\ r
Address i+g r, 0 L i r,.. Of
City L r State Zip a 7 3%y Phone 3 36
LOCATION OF PROJECT: (Address, street name and/or directions to site. If not oceanfront, what is the name of
the adjacent waterbody?) 4 80 S to i 1 6 (FPh n- RCI /-)P V r
ccAS T stdc CIP Ut,66=ba i C11rFal'�'_
DESCRIPTION OF PROJECT (List all proposed construction and land disturbance.) si�j�- JJs
PP
SIZE OF LOT/PARCEL: square feet % acres
PROPOSED USE: Residential (Single-family Multi -family ) Commerical/Industrial
Other
TOTAL ENCLOSED FLOOR AREA OF A BUILDING IN THE OCEAN HAZARD AREA OF ENVI-
RONMENTAL CONCERN (AEC):
square feet (includes all floors and roof -covered decks)
SIZE OF BUILDING FOOTPRINT AND OTHER IMPERVIOUS OR BUILT -UPON SURFACES IN
THE COASTAL SHORELINE AREA OF ENVIRONMENTAL CONCERN (AEC): sq. ft.
(Calculations include the area of the roof/drip line of all buildings, driveways, covered decks, concrete or masonry patios,
etc. that are within the applicable AEC. Attach your calculations with the project drawing.)
oose the AEC area that applies to your property:
(1 within 75 feet of Normal High Water for the Estuarine Shoreline AEC
within 575 feet of Normal High Water for the Estuarine Shoreline AEC, adjacent to Outstanding
Resource Waters
(3) within 30 feet of the Public Trust Shoreline AEC
(Contact your Local Permit Officer if you are not sure which AEC applies to your property.)
STATE STORMWATER MANAGEMENT PERMIT: Is the project located in an area subject to a
State Stormwater Man ement Permit issued by the N.C. Division of Water Quality?
YES NOT
If yes, list the total built -upon area/impervious surface allowed for your lot or parcel. square feet.

X t
y ja
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Michael F. Easley, Governor Donna D. Moffitt, Director William G. Ross Jr., Secretary
August 18, 2003
Mr. James A. Smith
275 Magnolia Drive
Reidsville, NC 27320
Dear Mr. Smith:
The NC Division of Coastal Management hereby acknowledges receipt of your application for
State approval for minor development of your property located at 680 Smith Farm Road in
Havelock adjacent to Clubfoot Creek in Craven County. It was received complete on August 14,
2003 and appears to be adequate for processing at this time. The projected deadline for making a
permit decision is August 28, 2003.
NCGS 113A-119(b) requires that Notice of an application be posted at the location of the
proposed development. Enclosed you will find a "Notice of Permit Filing" postcard which must
be posted at the property of your proposed development. You should post this notice at a
conspicuous point along your property where it can be observed from a public road. Some
examples would be: Nailing the notice card to a telephone pole or tree along the road right-of-
way fronting your property; or at a point along the road right-of-way where a private road would
lead one into your property. Failure to post this notice could result in an incomplete application.
An onsite inspection will be made, and if additional information is required, you will be notified.
Please contact me if you have any questions.
Sincerely,
•
Brad Shaver
Coastal Management Representative
bes
Enclosure
cc:Ted Tyndall, District Manager
151-B Hwy. 24, Hestron Plaza II, Morehead City, North Carolina 28557
Phone: [phone] FAX: [phone] Internet: http://dcm2.enr.state.nc.us
An Equal Opportunity 1 Affirmative Action Employer — 50% Recycled 110% Post Consumer Paper

PROJECT:
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Chi -f- Nil j%o/�C.��OLa�[� � � �$� Jwt• /` Fa��, Kd ih `sµ��
COMMENTS ACCEPTED THROUGH Alf
APPLICANT:
d QINL! A. SiN
Qe �dl v.ck. Arc ZVZo
FOR MORE DETAILS CONTACT
THE LOCAL.PERMIT OFFICER BELOW:
151- 6 &EX LY 17
Mveetie4 (: j,, ,lc ZeZ7 -
(ZSZ) So 9 - 28o8

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JAY SMITH 4606
NCDL 2105210 PH 336-349-6669
275 MAGNOLIA DR
/� r p
REIDSVILLE, NC 27320 �,V 66-49/531 CC
Date
Pay To The ,-------- —�
Order Of /��• D (�
Da -liars
A�J CHoyu
Wachovia Bank, N.A.
R&le illq NG 27320
Memo AlWAR f'PP Fib
I:0531004941: 6337 L L 13 I',�606

DIVISION OF COASTAL MANAGEMENT
NCDENR
NORTH CAAOUNA DEPARTMENr or
ENVIRONMENT AND NATURA4 RESOURCES
151-B HWY. 24, HESTRON BUILDING
MOREHEAD CITY, NC 28557
TELEPHONE: [phone]
FAX: [phone]
TO: Su r -Jb urv4 L
OFFICE: 4L A 77Sgej& SCC776 /
TELEPHONE #: t 1 FAX #: f Zs21 lo33-io //
FROM:
OFFICE: DIVi ION OF COA 'THI. k ANAGP k,fF T
RE:
DATE SENT: A A '
TOTAL NUMBER OF PAGES �T JDING nyFR SHEET:
3

- WA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Michael F. Easley, Governor Donna D. Moffitt, Director William G. Ross Jr., Secretary
August 18, 2003
The Sun Journal
Legal Advertisement Section
P.O. Box 1149
New Bern, NC 28563
Re: Public Notice — James A. Smith
Dear Sir:
Please publish the attached Notice in the August 20, 2003 issue of the Sun Journal.
The State Office of Budget and Management requires an original Affidavit of Publication prior
to payment for newspaper advertising. Please send the affidavit, an original copy of the
published notice, and an original invoice to Jaye Poole, NC Division of Coastal
Management, 1638 Mail Service Center, Raleigh, North Carolina 27699-1638, Telephone
[phone].
Thank you for your assistance in this matter. If you should have any questions, please contact
me at our Morehead City office [phone].
Sincerely,
Brad E. Shaver
Coastal Management Representative
bes
Enclosure
cc:Ted Tyndall, District Manager
151-B Hwy. 24, Hestron Plaza II, Morehead City, North Carolina 28557
Phone: [phone] FAX: [phone] Internet: http://dcm2.enr.state.nc.us
An Equal Opportunity 1 Affirmative Action Employer — 50% Recycled 110% Post Consumer Paper

NOTICE OF FILING
OF APPLICATION FOR
CAMA MINOR DEVELOPMENT PERMIT
Notice is hereby given that James A. Smith has applied to the Department of
Environment and Natural Resources for a Minor Development permit. The applicant is
requesting to stabilize the existing shoreline with rock at 680 Smith Farm Road adjacent to
Clubfoot Creek in Craven County.
Persons desiring to inspect the application, or to comment thereon, are directed to contact
Brad Shaver, Coastal Management Representative, NC Division of Coastal Management, 151-B
Hwy. 24, Hestron Plaza II, Morehead City, NC, Telephone [phone], no later than August
r
27, 2003. Comments received prior to that date will be considered in making the permit
decision. Later comments will be accepted and considered up to the time of permit decision.
Project modifications may occur based on further review and comments. Notice of the permit
decision in this matter will be provided upon written request.
PLEASE PUBLISH ON: August 20, 2003

P. 01
TRANSACTION REPORT
�c AUG-18-2003 MON 10:26 AM %K
�c DATE START RECEIVER TX TIME PAGES TYPE NOTE M# DP
�c AUG-18 10:21 AM 82526331841 1'43" 3 SEND OK 746

STATE OF NORTH CAROLINA SUBJECT em I-T Ro PROJECT r
DEPARTMENT OF TRANSPORTATION %V1 COUNTY
DIVISION OF' HIGHWAYS
HIGHWAY BUILDING PREPARED BY DATE 8 S e3' STATION
P. O. BOX 25201
RALEIGH. NORTH CAROLINA 27611 CHECKED BY DATE STR NO 1 SHEET OF
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ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to
(Name of Property Owner)
property located at ITIA E7-'PM BOA 0
(Lot, Block, Road, etc.) . '
on in AA VeW-e(Ce-AV&rJ0 ouA1 ty) , 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 to his proposal. AUG 1 4 2003
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(To be filled in by individual proposing development)
IAu ID S'.* 52r-mbA
Print or Type Name.
qiq-,),66-3aad
Telephone Number
Date:

SENT BY: ; 336 854 7784; JUL-22-03 17:13; PAGE 2/2
Jul 22 03 10:47a Harru Lee Manuel i3361 349-6646 p.2
ADJACENT RWARIAN PROPERTY OWNER STATEMENT
I hereby certify beat I own property adjacent to'l ,s
clv oe petty Owner) AM x 4
property located at
2003
Block, Road, etc.) -
on , l x-l" 4' C!G G , it1 Ave / G/. ��'Q YG/% , N.C.
(Waterbody) (Town and/ r County) .
He has dr.='bed to me as shown below, the development he is proposing at that Iocas on,
and, I have no objections to his proposal
DESCRIPTION AND/OR DRAINING OF PROPOSED DEVELOPMLNT
(To be fdZed in by individual proposing development)
SignatuT ,
print or Type Nwnc.
33� ?5V- -7-7-71
Tel hone Nuffiber
Date: -IbS • 0

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 list 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: AUG 1 4 2003
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)
_T— an owner or record title. Title is vested in, I Rm ES A raV l 0 -SIr.l 1 h , see Deed Book .10 Zo
page — in the CYp V -N 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 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) gAT17),4 N Srn, i i k - 5a6l-f w,l _av-J Rcl, Datc Otd% a MC. a r)3/0
(2) Dr��i�cl \, a- 13r�Nc�n 5-.Ao4* J3nTl.lchrn• /�c[, hZALt,9{� N�, ��6to
(3)
(4)
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 associ-
ated with this lot. This explanation was accompanied by recommendations concerning stabilization and floodproofing tech-
niques.
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 infor-
mation 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 issued. Deviation from these details will constitute a violation of any permit. Any
person developing in an AEC without permit is subject to civil, criminal and administrative action.
This the Mo day of , 2060
Landowner or person authorized to act as his agent for purpose of filing a CAMA permit application.

SITE DRAWING/APPLICATION CHECKLIST
Please make sure your site drawing includes the following information required for a CAMA minor development
permit. The drawing may be simple and not necessarily to scale. The Local Permit Officer will help you, if
requested.
PHYSICAL DIMENSIONS
Label roads
Label highways right-of-ways
Label local setback lines
Label any and all structures and driveways currently existing on property
PHYSICAL CHARACTERISTICS
Draw and label mean high water mark
Draw location of on -site wastewater system
If you will be working in the ocean hazard area:
Draw and label dune ridges (note height)
Draw and label toe of dune
Identify and locate first line of stable vegetation
Draw and label setback line under CAMA
Draw and label topographical features (optional)
If you will be working in an estuarine shoreline area:
Draw and label landward limit of AEC
Describe terrain (slope)
DEVELOPMENT PLANS
Draw and label areas that will be disturbed
If a house is to be placed on lot, describe location of house
Note size of piling and depth to be placed in ground
Draw and label all areas to be paved or graveled
Describe composition of surface
Note and list fully all trees and vegetation to be removed or relocated
Show landscaping
NOTE TO APPLICANT
Have you:
• completed all blanks and / or indicated if not applicable?
• notified and listed adjacent property owners?
• included your site drawing/
• signed both a poication and statement of ownership?
• enclosed the TI 00.00 fee? W 'Df A11Z
• completed an AEC Hazard Notice, if necessary?
FOR STAFF USE
Site Notice Posted Final Inspection Fee Received
Site Inspections
Date of Action: Issued Exempted
Revised 3/2003
Denied Appeal Deadline (20 days)