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AGENT AUTHORIZATION FOR CAMA.PERMIT APPLICATION
Name of Property Owner Requesting Permit:��
Mailing Address: / 7 05 A✓t-/lDI A'L®A/T�
64-Al , e--4 i/-773
Phone Number: '510/ 4 (3b ay�
Email Address: A1771C)
f certify that I have authorized
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
at my property located at 40 a C--
in /6?e( t5 "Ve-leCounty.
1 furthermore certify that / am authorized to grant, and do in fact grant permission to
Division of Coastal Management start 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
X7tti� OGJ�c/��
Title
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Dale
This certification is valid through / l

DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION FORM
CERTIFIED MAIL - RETURN RECEIPT REQUESTED
I hereby certify that I own property adjacent to Qh to has 's
(Name of Property Owner)
property located at ��o� tt . �llst r
(Address, Lot, Block, Road, etc.)
on f4I lu H/ in ©a, t- -T-S l., c� N.C.
(Waterbody) (City/Town and/or County)
Agent's Name #:
Agent's phone #:
Mailing Address:
He/She has described to me as shown below the development he/she is proposing at that location,
and I have no objections to the proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
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If you have objections to what is being proposed, you must notify the Division of Coastal Management
(DCM) in writing within 10 days of receipt of this notice. Contact information for DCM offices is
available at httpJ/www.nccoastalmanagement.net/web/cm/staff-listing orby calling 1-888-4RCOAST.
No response is considered the same as no objection if you have been notified by Certified Mail.
(Property Owner Information)
Signature
Print or Type Name
Mailing Address
City/State2ip
Telephone Number / Email Address
Date
(Riparian Property Owner Info mation)) J_ ,
Signature
S7 V4 4&1 cv A.•%J S
Print or Type Name
11401 f, as 1 Ts Lxpl J Dv,, -
Mailing Address
©c,!-- Ts Alc ZgLlGS
City/State/Zip
1/0 - 20/- SaS'Z
Telephone Number / Email Address
//- /y-
Date
(Revised: Aug. 2014)

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSIBOATI.IFT/BOATHOUSE)
I hereby certify that I own property adjacent to n is
(Name of Properl caner)
property located at
L
(Lot, $lock, Road, etc.)
on 6-T— W'' in Q q f T s l an d , N.C.
(Waterbody) (Town and/or County)
Applicant's phone t/:
Mailing Address:
He has described to me, as shown below, the development he is proposing at that location, and,1
have no objections to his proposal. I understand that a pier/mooring pilings / boatlift / boathouse
must be set back a minimum distance of fifteen feet (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 not wish to waive
I do wish to waive that setback requirement.
--------------------------- -------- -------------------------------------------------------------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
A)6 dp3-�E-C l 16.E 0 - rZ6popoStL- s �,j k /i 1,
-------------------------------------------------------------------------------------------------------------------
(Information for Property Owner Applying (Riparian Property Owner Information)
for Perin it)
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Mailing Address
Signature
City/State/Zip
Telephone�er
Signature
Date
Jan �Gr��Un
Print or Type Name
quo-2l`f—gZ2Z
Telephone Number
--r
Date

ADJACENT RIPARIAN PROPERTY OWNER
STATEMENT FOR CAMA MINOR PERMITS
I hereby certify that I own property adjacent to -Ron Tan aq s
(Name of Property Owner)
property located at "1 � 2 �, . yA C k N-
/�
.LW t / Address, Lot, Block, Road, etc.)
Pon W , in Oak N.C.
(Waterbody) (Town and/or County)
He has described to me as shown in the attached application and project drawing(s), the
development he is proposing at that location, and, I have no objections to his proposal.
APPLICATION AND DRAWING OF PROPOSED DEVELOPMENT ATTACHED)
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Tature
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Print or Type ame
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Telephone umber