74801D - Dawley

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
G4r1 {
Name of l'rooerty Owner Requesting Permit: ��yO
Mailing Address ' p'6 SW Z
-
Phone Numoe- c 1 O oZ.-1 t3 Sy 1 ? -- --
Finail Address:
certify that I have authorizedy-� t�/ Qyr �V t�L,
Agent! Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development - _ .I, ;
at my property located at
in &Y%r4Sm3+cJc County
1 furthermore certify that i am authorized to grant, and do in fact grant permission to
Division of Coastal Management staff, the Local Permit Officer and their agents to enter
on the aforementioned lands in connection with evaluating inforrnation related to th,s
permit applrcatrnr+
Property Owner Informatior.:
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Pnnt or Type Flame
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Date
This certifir-abon is valid through t !

ADJACENT RIPARIAN PROP RTY OWN STATE NT
I herepy Certify that I rwn property adjacent toP40AC
w
property located a: to _ ` (Name of Property nor)
on
(Address, Lot, t3lock d, etc.)—
t; C4'�1 in _ Q�V_ I S1Ar•d
(Waterbody) --� N C
(City/Town andlor County)
The applicant has descrobed to me, as shown below. the development proposed at the above Nation
have no objection to this proposal
I have objections to this proposal
DESCRIPTION AND/OR DRAWING OF PROPO5ED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing,
WAIVER SECTION
I understand that a pier, dock, mooring p,6n9s, breakwater. boathouse. lift, or groin must be set back a
minimum distance of 15, from my area of riparian access unless waived by me (If you wish tc waive
the setback, you must initial the appropriate blank below
_. I do wish to waive the 15 setback requirement
I do not wish to waive the 15' setback requirement
(Property Owner Information) (Adjacent Property Owner Information)
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ure
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Madrng� Foss
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(Revrsed 611 W2012,

A ,JAC�t RrPARtJt!t
OPF TY OWVER STATEMFfi
t 3rCc y :y1S1'y fh3' ,1;,. .':c,.i' IC• ,rK,cL *".l
.caf:.a . V"C1..�y (Marra of Prope!ly 6co —
ol) ;ti,1S C�iAttdress:-ot. SIXk Road. etc.
ivlato t,<�dy, I., Lek
(City;To:rn antittar Countyl
(he �:•K"9�5. firs .'r�:11..'1r' is �!'f i. S'tJ'.YP, Ccl.;.•,, the dovq .:Ctlje r"r]':1el 3! It
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tilt 'O
---------------
"ESCRI?jt'lON tiK,a'OR UkAVVING OF PROPOSEO DFVELOPMENT
(lfldrvidual tuapol-mg rletrwx+putcrtt r►Irst ftY in doscription Leioti or JURch a .cute draw.aq.
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,9 ,� ' ds rJ,rilKw.rx• bca�r'E
P- trcr, J. r' R'Ls' be 5:1 t !=. ;
the L�'_,1L, tr0 1 mus" Irt I J"C3 t :7.Z 1p" 3 Ce55 tn9 Fi5 ,•.;. y, :. jll r:.. Rt�" I: v.khh a! 11"w 'eWcuf -'e _ •,rl< I:?loW.
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do not
Wroperty Owner Infotmalion� —
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Cheek
Dafc Neccived
Date 0—sited Check From /Name)
Name o/ Perms( Holder
Vendor
er Numb
amount
Permit Number/Comments
Receiof or Relund/Reallocated
ColumM
Columns Column3
_ Column4
_
Colum_n5_
7Chock
mn8
Column?
Columnll
Column9
11/27/20191 11/27/2019 McPherson Marine Services LLC
!Earl & Martha Dawley
ank
2152:
$ 400.00
GP 74801 D
'Tmac ret. 9498D