98-0021_Roslie, Terry and Mahalah_19980805

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Locality Pam [ I C0 6A Permit Number 0 ao
GENERAL INFORMATION
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AUG 0 5 19
LAND OWNER r"
Name
Address <i 1 5T
City T yf1 - fL A �� State 1456el Zip v Phone(f0y
AUTHO ZED AGENT
Name t�
Address
City w544j- I 1 State /�� Zip-Phone:���`�Y'�
LOCATION OF PROJECT `V1� lei 14
(If not oceanfront, is waterbody natural or manmade?) )4 Z1Ie-'-f,L
DESCRIPTION OF PROJECT &:2� - aZ W i 3 t X JI
AREAS OF ENVIRONMENTAL CONCERN (AEC) CLASSIFICATION
(To be filled in by the Local Permit Officer prior to completing application.)
Ocean Hazard _V_ Estuarine Shoreline ORW Shoreline Other
PROPOSED USE
Residential Commercial/Industrial Other
SIZE OF BUILDING IN SQUARE FEET
Size of other impervious or built upon surfaces (such as driveways, etc.) within 75 feet of the shoreline (575 feet
of an ORW shoreline)
SIZE OF SITE IN SQUARE FEET
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 com-
plied 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 LAMA, only a sugges-
tion to help you complete your project as quickly as
possible.
Zoning, Drinking Water Well, Septic Tank (or other
sanitary waste treatment system), Burning, Electri-
cal, Plumbing, Heating and Air Conditioning, In-
sulation and Energy Conservation, FIA Certifica-
tion, Sand Dune, Sediment Control, Subdivision..
Approval, Mobile Home Park Approval, Highway
Connection, Others:

STATEMENT OF OWNERSHIP
I, the undersigned, an applicant for a CAMA minor development permit, begin 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 sig-
nificant interest in the real property described therein. This interest
��can
jbe described as follows: (check one)
an owner f record title, Ti e is vested In [Q h G, Ic.g6 , see Deed Book
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 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
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�%,� �,,C' C5'r �, ��(t Apt � 11isz�C.'► EL Cs�G` i5ox i%mot
(2) ZtiA # 4s �P
(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 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 ap-
plication, the ownership statement, the AEC hazard notice where necessary, a check for $50.00 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 maybe issued. Deviation
from these details will constitute a violation of any permit. Any person developing in an AEC without a per-
mit is subject to civil, criminal and administrative action.
This the- day of 19.
t-
Land o r or -person authorized to act as his agent
for purposes of filing a CAMA permit application.

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