71816D - Harrington

AGENT AUTHORIZATION FOR GAMMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: _ l
Mailing Address:
Phone Number:
Email Address:
I certify that I have authorized
Flgent I uoniracwi
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: _ r�cl- D`VIC
at my property located
in gf�ACounty.
I furthermore certify that 1 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:
// sign6ture %
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Print or Type —Name
Title
3 I a__ ,',�-�—_
Date
This certification is valid through .1--)^1___4-1-2;kLT

r i ; r � JD ,If r 'L I�,: 1_ . �1_L :d_ j:.tilJ 1, , ► �►)
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ADJACENT RIPARI'AN PROPERTY OWNER STATEMENT
1 'ee,y certify that I own proper.; adja :entto
.�
c,operty located at .� � I
(Address, Lot, Bloc
or 4 , in
(Waterbody)
r)
, etc.)
(City/Town and/or County)
's
N.C.
The applicant has described to rne, as shown below, the development proposed at the above
loc—
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 desc �Io elow or attach a site drawing)
IK-
C�_,
C
sw -
WAIVER SECTION
R001 ) �t — 3 y�
i
I understand that a pier, dock, mooring pilings, boat ramp, 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) (Adjacen Prope Owner Information)
' s
t i F iP, natur
�
�nnr c� yC e m.e Print or TySZAe cam (/I C�
<_ -e "( a^nD er / mail address v—
Mailing
v —
Telephone NumbTrlenTil addre s
Date *
(Revised Aug. 2014)
, = _ jor one calendar year after signature*

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ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to 's
roener
p )
property located at /< =� � f
(Address, Lot,
on ql� J in
(Waterbody)
lock., Rpad, etc.)
(City/Town and/or County)
N.C.
The applipant has described to me, as shown below, the development proposed at the above
locatio .
1 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 desc o below or attach a site drawing)
...... ...... . —:;
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, 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.)
do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Own
Jer Infonnation) (Adjacent Property Owner Info tion)
Sign ure
Signature
Print or ype *ne Print o Type Name
SQ1.5/ ry �Gd [ E. �el� 7r.1,�.J
Marlin dress 1—wery P. Mailing Addrpss
City/State/Zip City/State
Telephone Number/ mail address Telephone Number/email address
Date / !11
Date* 3 z. 2 j
'Valid for one calendar year after signature' (Revised Aug. 2014)

Date Received
D.I. sited Check From Name
Name of Permif Holder
Vendor
Check Number
Check
amount
Permit NumbwlComments
Receipt or RefundMeagocated
Col —I
C011nmtl
Cc/umn3
Column)
ColumnS
Column6
Column?
Column8
C.4m 9-
402019
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