71829D - Selle

AGENT AU'rHORIZATION FOR CAMA P'Ef2LIT APPLICATION
Name of Property Owner Requesting Perriit:
Mailing Address: _ �Ur.✓�f( ,A t
Phone Number:��' �v_...
Email Address: _ /,e kd"W'
I certify that I have authorized
Agent I ',ontractor
to act on my behalf, for he purpose of applying for and oh aining all CAMA permits
necessary for the follow ng proposed developrrier;t: _ _ ,1/ r-��G Ila
at my property located at �� � 0171 TS11)1
in ." r ('t County.
1 furthermore certify that 1 am authorizes to grant, and (!o in fact grant permission to
Division of Coastal Man9gement staff, the Local Peimi� O-ficer and their agents to enter
on the aforementioned lands in connecti.)n with eial-,ia` '7g information related to this
permit application.
Property Owner Information:
rllt� - A
ignatur:
Print & Type -Vame
lk 4
Title
3-
Date
This certification is valid through_/_/6 _/_J-7

ADJACi:NT RIPARIAN PROPERTY OWNEr �STATEMENT
I hereby certify that I own ,:property adjacent to i✓�� �S ..__ . �U'Z s
/q � 4) �h` (1 p,! of Property Owner)
ro ert located at
P p J on Aids
(Waterbody)
(Address;, Lot, Slook, R2 , idetc.) 1
-- it __ 5�
(City.!' 'own and/or County)
N.C.
The applicant has descrited to me, as shown below. the deg- lopment proposed at the above
locatio
I have no o,,ajection to this proposal.
I have obje^1tions to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOE :D DEVELOPMENT
(individual proposing development must fi.il in descrintion )elow or attach a site drawing)
-�-6 e�� R 429t4
WAIVER SECTION
understand that a pier, clock, mooring piling:, boat rarr p, -ikwater, boathouse, lift, or groin
must be set back a minimum distance of 15' rom my ar-)a i:,f r parian access unless waived by
me. (If you wish to waive tiie setback, you must initial th= appr )priate blank below.)
I do wish to viaive the 15' setbac: requirE)MOnt
I do not wish, to waive the 15' setback requi ^er ,ar
(Property Owner I forn rt' n) (.Adj,,.cell, .,roperty Owner Information)
cy ic��
Signature
Gtti k�� ve olw�✓cis
Print or Type ame F'r nt �r p Name
5 1 _ `�G o/ ..�' , ©p lc % "cl 6 r
M ling Addr ss Maihr�c A-Ic ass
City/State/Zip Ci`y/' taG^lZ
�94 l259b We —_�to. - a of - SaSz-
Telephone Nup7berlemail address Telephone ,amber/email address
3 '26 / - -- -5,-_ '? - I?
Date ,':ate'
(Revised Aug. 2014)
`Valid for one calenc ar year after signature:"

0 70173380000086271434
Add Name
Delivered:
IRON STATION, NC 28080 on
April 10, 2019 at 12:34 pm
Additional Information
Your item was delivered to an individual at the address at 12:34 pm on April 10, 2019 in IRON STATION, NC
28080.
Tracking History
April 10, 2019
12:34 pm
Delivered, Left with Individual,
IRON STATION, NC 28080
April 6, 2019
12:46 pm
Notice Left (No Authorized Recipient Available),
IRON STATION, NC 28080
April 6, 2019
10:27 am
Out for Delivery,
IRON STATION, NC 28080
April 6, 2019
10:17 am
Sorting Complete,
IRON STATION, NC 28080
April 6, 2019
9:52 am
Arrived at Unit,
IRON STATION, NC 28080
April 5, 2019
In Transit to Next Facility,
Postal
Service'"
L
RTIFIED.MAIL°
RECEIPT
stic Mail
Only
ivery information,
visit
our website
at www.usps.com" .
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https:(1m.usps.com/m/TrackConfirmAction_detail?tLabels= 70173 38000 008 6 2714 34 5129/19, 6:05 PM
Page 1 of 2

April 2, 2019
5:31 pm
Departed Post Office,
OAK ISLAND, NC 28465
April 2, 2019
2:26 pm
LISPS in possession of item,
OAK ISLAND, NC 28465
`?ttps:/Jtn.uses.com/in/TrackConiirmActfon_detail-?t .abeIs=70173380000086271434 5/29/19, 6:05 PM
Page 2 of 2

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Oats Received
Dare Deposited Check From Name
Name of Petmlt Holder
Vendor
Chxk NNumberamounf
Check
Permit NumbenCommenfs
Receipt or Relund/Realkxated
Columnl
Co1umn3
Col-3
Column{
Columns
Column8
Column7
Column8
Column9
6612019
AheeM n ontr tors LLC
I ChnSAe
itizens Bank
5
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IGP#718
46