71849D - Long

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit:
Mailing Address: 3506
Phone Number:
Email Address:
I certify that I have authorized
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Agent I Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: 1L' Q;�
at my property located at
in Aruvrsu"' County.
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 infb47ation related to this
permit application.
Property Owner Information:
Signature
G �rjt car \---0 Na
Print or Type Nam
_ CJw n �(
Title
Date
This certification is valid through ✓2 1 .2 1 -')O

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to I % . 1. g p_N G is
I ff (Name of Property O er)
property located at �iJG V E yQ c kA r O)<q:
�/ (Address, Lot, Block, Road, etc.)
on ` A in (MY�: ,s\dVX , N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above location.
J 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)
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.
L I do not wish to waive the 15' setback requirement.
(Property Owner Information) (Adjacent Property Own information)
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Signature Si ature
S-fe �le rif.,'a
Print or Type Na e Print or Type Name
Mailing Address Mailina Address
3306 Ya c h-� Ac- a K--x- ra le ; lei nn /-L"
City/State/Zip City/State/Zp
oci�, PU �, a4ybS 11i�-a?vl-ysZ
Telephone Number Telephone Number
Date Date
(Revised 6/18A2012)

&P-1�GENT F21PAR AN PROPERtTlY� 04y1� R STAT1aKI
t hereby certify that I own property adlaxn, t
Name of P Owner)
property located at WCPS
(Address.—ofBlpcic, R etc
or, Ictu I in t7 KC
(Watwbody) (Cityrrown andror county)
The has described to me, as shrwr beiaw, the developrrtnt .�Cposed at tho above
I have no objection to this ;proposal
I have ob)ecSCrn to tr:s prcpcsal
DESCRIPTION ANDiOR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fell in description below or attach a site drawir'W
&' i� y-a�. Qx k- DfaIl A g a o •c
WAVER SECTION
1 understand " a per. dock, mooring plings. brealtwa . boathoum WL or groin must t o set back a
rriri. rum distance of 15 from my area of ttparhn nooaas unlsas waived by no. of you w.sh to waive
the set jrtc you must I MIA the appropriate t L&* below.)
1 do wish to wave the 15' setback req,-irement
I do not ✓ ish to waive 1�ie 15' setback requremcnt
(Property Owner Information) (Adjac Property or Iq/ortnation)
Signature SJ�i� k QU
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