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Beach
Other
Shoreline Length -+
SAV: not sure yes
Moratorium: n/a yes
Photos: yes
Waiver Attached:
A building permit may be required by: 10/ je� ei�l El See note on back regarding River Basin rules.
( Note Local Planning Jurisdiction)
Notes/ Special Conditions
** Please read compliance statement on back pfpermit **
Application Fee(s)
Check #
tO icer's Printed Name
S' atu
l -3/ - /,�F �-1
Issuing Date Expiration Date

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: �� `1 l • r �(Z
Mailing Address:
Phone Number: CID "'U 90 q _
Email Address:
I certify that I have authorized
Agent /
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: 'E09 3
�w
13u1 IL he'-'40 ge-pLocm eA*
at my property located at
in County.
l 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 information related to this
permit application.
Property Owner Information:
Signature
Print or Type Name
b cj-L
Title
Date
This certification is valid through i ll l

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to 's
dame of Pro rty Owner
property located at b 10 �l dl CAr_ �, ,, I I .o N
�� 1 L_ (Addris, Lot Block! Road etc.)
on _ , in 3 1 , N.C.
(Waterbody) (City/Town andlot County)
The applicant has described to me, as shown below, the development proposed at the above location.
I have no objection to this proposal,
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
110 D t C f+?J r,')
WAIVER SECTION
1 understand that a pier, dock, mooring pilings, 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 to 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)
�ignalure iprratul•e
i MAM 1. lie-Rtzi ��
Print or Type Name
h4- S7,od►,�
Mailing Address
_Pi1PAQ40Q��-S s 31ob
Crty/state2ip
- qci Q
Telephone Number
1- )c0— 1G
Date
(Revised 611612012)

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to 11 s
property located at �1�(Name of Property Owner) c
t� �(�Addre*s�s
�Iock.,
-� i �J� Lon t •} "���- (� L Road,
(Waterbody) , in 1::C�l�1 N.C.
(City/ I own and/or County)
The applicant has described to me, as shown below, the development proposed at the above location,
i have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
A' W;Wrri
�xi ba'G la
��'QLRG�- Se�►,�xatL
tom tAj- b'N 1-� 0( bL" )1eC e;�i �1
J ,
WAIVER SECTION
I understand that a pier, dock, mooring pilings, 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 to 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 one .Information)
Signature —
u--
Si n ure
Ten c - �aerGta�dd-�
Print or Tye Name Print or T pe Narne.
Mailing .Address . Ma � ing Address.:
City/State/Zip Ciry/Stat
� � � z7Tel4p'D—ne Number Telephone Number
Date ` .�_%
Dale
(Revised 6/1WO12)

� eV-Unc- c,
lzv,1 )<he.ra.3.
y`1;11; Rm

Date Received
Date Deposited Check From Name
Name of Pennit Holder
Vendor
Check Number
Check
amounf
Permit Number/Comm—m
Recel t or Refund/Reallocated
Columnl
Co1umn2 Column3
Column!
Columns
Column6
Column?
Cofumn8
Column9
14 019.
W,Iliam T and Sharon C Hemn a
William Hemn,
st CMzens Bank
16507
S
QP k7 7 3