Daniel, Gloria

(1 i f IA / ❑ DREDGE & FILL No. 75758 A B l y' D
L A ", IJERAL PERMIT Previous permit#
G Iev? ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality .-71/ /
and the Coastal Resources Cc mission in an area of environmental oncern pursuant to 15A NCAC / /
�Y ❑Rul attached
Applicant Name_ `' �}1� I L � � � I {� Project Location: County
Address V r� 7 / �C� /��c %. 77 Street Addres tS at(a
# - Road/ otr(s)
City ... " State ZIP tX l C 7 1f 7
Phone ) )/fE-Mail Subdivision
Authorized Agent ! l_ City r G f ZIP
Affected pCW ]EW PTA ❑ES ❑PTS Phone# O River Basin •../ 'r' %.
Affecte El OEA ❑HHF ❑IH ❑UBA ❑N/A Adj. Wtr. Body © °i L"' ' na man unkn
❑ PWS: /
ORW: yes / no PNA yes / no Closest Maj. Wtr. Body r
Agent or Applicant Printed Name
Signal '** Please read compliance statement on back of permit"
`•�ication Fees) Check #Feels) Check #
t.-
PermitOffcer's Printed Name
Signature4y7I-7
Issuing Exp} ation Date

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATIQ
Name of Property Owner Requesting Permit: . t -X�ll11PI
Mailing Address:
Phone Number:
Email Address:
certify that I have authorized
Owl —A
�W1101 41 J • �� _��
Agent / contractor
narA
to act on my behalf, for the purpose of applying for and obttainingl `all CAMA permits
necessary for the following proposed development: en
at my property located at rc
in Carl i �� County.
l furthermore certify that / am authorized to grant and do in fact grant permission to
Division of Coastal Management staff, the Loral Permit Officer and their agents to enter
on the aforementioned lands in connection with evaluating information related to this
Permit application.
Title
Date
This certification Is valid through

CERTIFIED MAIL RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner:
Address of Property: _� 2 S S� A 9r- (1G�c_lo onit a-r—
(Lot or street #, Sireet o
City $ County)
Agent's Name #: Mailing Address:
Agent's phone A
I hereby certify that I own property adjacent to the above referenced property. The individual
applying for this permit has described to me as shown on the attached drawing the development
they are proposing. A description or drawing, with dimensions must be Provided with this letter.
I have no objections to this proposal. I have objections to this proposal.
Ifyou have objections to what is being proposed, you mustnoafy the Division of Coastal Management
(DCM) in writing within 70 days of rece/pE of this notice. Contact information for DCM offices is
avallab/eathtto://www.ncceastatmanaaementnet/web/cm/stafflisfrn orbycalling l-B88.4RCOAST,
No response is considered the samw a� .,� ..w,e..•.,...:�.._..
WAIVER SECTION
1 understand that a pier, dock, mooring
be set back a minimum distance of 15' orn my areaofriparian access unless waivedp, breakwater, boathouse, orlrft by me.t (if
you wish to waive the setback, you must initial the appropriate blank below.)
_ I do wish to waive the 15' setback requirement.
UI do not wish to waive the 15' setback requirement.
(Property Owner Information) (Riparian Property �Owner Information)
Signature
S' ature
(I I L2IR hf aoyii- t�i� ewer E�wo��c1S Qr
Print or Type Name Print or Type Nam
( 29U M m� nog Er
Marling Address
31,tMM ;e t Y "AL-2-1
Cdy/StatelZrp
(3310^`� at �t�r�h12�c<>I
IelephoneNumber/Email ddress
Melling Address
City/State/Zip
Cart 1710 3b4-44zoz
Telephone Number/Email Address
(Revised Aug. 2014)

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF MENT
ADJACENT RIPARIAN ROPER COASTAL OWNER NOTFE ATIONIWAIVER FORM
Name of Property Owner. G ( ry IA j )ou-\r l
Address of Property:
(Lot or Street #,
or Road, City &
Agent's Name #: _ Mailing Address:
Agent's phone #:
I hereby certify that I own property adjacent to the above referenced property. The individual
applying for this permit has described to me as shown on the attached drawing the development
they are posing. description or drawing with di
// men tons t be orovitled with this letter,
I have no objections to this proposal. I have objections to this proposal.
If you have objection to whatis being proposed, you must notify the Division of Coastal Management
(DCM) in writing within 10 days of receipt of this notice, Contact information for DCM offices is
l� WAIVER SECTION
I understand that a pier, dock, mooring
�1 ft mus
be set back a minimum distance of 15' fromMYareaofriparian access unless waived p, breakwater, boathouse, or liby met (If
You wish to waive the setback, you must initial the appropriate blank below.)
wish to waive the 15' setback requirement.
do not wish to waive the 15' setback requirement.
(Property Owner Information)
Signature
1 r ,? Ip, t
Pnnt or Type Name
_I RaiL3 ri(hU my
Marling Address
CI(y/State/Lp
a il� ti -I-1)nGtfi�
Telephone Number/Email—'Address
— ioI: llcQ
Date.
(Riparia tarty Owner Information)
S ture
Punt or Type Name
f
M�atingAddresq
Cdy/State2ip /
CC. �//" Goo-773'`Oad`r%�%�irziS/i/Y��cf'
Telephone Number / Email Address
Date
(Revised Aug. 2014)

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