99-0014_Coglo, Buddy_19990701

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Lo ality JIM 1; rn l0 Permit Number / q- 0 0
GENERAL INFORMATION
LAND OWNER
Name
Address
rd.
JUL 01 1999
City a l� State _/(,4 i� Zip X 762,7 Phone %11.771-4 r-r-
AUTHORIZED AGENT
Name
Address
City
State Zip
LOCATION OF PROJECT ��,Z S- J',QJ 4D2:!-;y47
Phone
(If not oceanfront, is waterbody natural or manmade?) x A�2
DESCRIPTION OF PROJECT I -A 1j p rC.e944,,' 4,W 61 S
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
SQUARE FOOTAGE OF BUILDING FOOTPRINT AND OTHER IMPERVIOUS OR
BUILT -UPON SURFACES (such as driveways, etc.) within 75 feet of the shoreline (575 feet
of an ORW shoreline) A„yo l
SQUARE FOOTAGE OF TOTAL FLOOR AREA OF BUILDING
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.

5
J U L 0 1 1999
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)
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�rcLnC.e ►
�n owner or record tit , Title is vested in i;0 ,/see Deed Book
page�� in the m1.,cn 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 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)
Jr
(2)-r—h4r-- i
(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 may be 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 2S day of "=-U-Z- ,19qI .
Z��
Land owner or-pet<oin au orized to act as his agent
for purposes of filing a CAMA permit application.
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June-25-99 O6:10A Floyd Bridgwater 409-862-2629
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