67901D - Dagenhart

Pat McCrory
Governor
AV—
NCDENR
North Carolina Department of Environment and l
N.C. Division of Coastal Manager
V>
�E CiVED
[)CM WILMINGTON, NO
AGENT AUTHORIZATION FORK DEC 1 4 2016
Date: 3L, Nei), Vj`
Name of Property Owner Applying for Permit:
� rv-mu 6&4.—eN �, Al r
Owner's Mailin,�q Address:
o) P. f 1,� �r% 5'rl
S � T1.4
gr,rib'
Email C�,rQh C jn�%N,JNt'W�,Ctn+�
1
Phone
Name of Authorized Agent for this project:
Agent's Mailing Address:
• AV.
RO RAY 8W
Wrightsville Beach, NC 28480
Email: [phone]
Phone
I certify that I have authorized the agent listed above to act on my behalf, for the purpose o
for, and obtaining all CAMA Permits necessary to install or construct the following (activity)
P, , �lJ51; ff" r�lown N �J a 11 i -)3 ; ���s ;z 131, &A ao-.;
For my property located at
This certification is valid 1 year from (date) 3v A%L0b'li,
n..trea�'
SCMVgx8* 21®
D.
° °r ,C
F �3�62
I unnr►•, UI�I"

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
Name of Property Owner: i✓ac
Address of PropertGy: r 0?c� f �, j**w Ai : , Az
(Lot or Street #,
Agent's Name#: Pd /% N
Agent's phone #: P" vi, d,)-,
(Road, CItty & County)
Mailing Address: , P� i
�I ,v4pVon
I hereby certify that I own property adjacent to the above referenced property. The individual
applying for this permit has described to me as shown on the attached drawing the development
they are proposing. A desrxiptittn or drowirta with dimensions: must be provided with this letter.
have no objections to this proposal. 1 have objections to this proposal:
Ifyou have objections to what is being proposed, you must notify the Division of CoastalAlanagement (DCM) in
writing within 10 days of receipt of this notke. Correspondence should be malled to 127 Cardinal Drive Ext,
Wilmington, NC, 28405-3"5. DCM mpnesentatives can also be contacted at [phone]. No response is
considered the same as no objection Ayou have been nod ied by CerBtied MAN.
WAIVER SECTION Sri
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 i it I 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)
Signature
�.h"'
Pant orType pie
;A)U, 5t, 5u,�
Mading Ad ss
Information)
)�m
Print or Type Nahm
93J, &—J64
Mading Address
rrn,ir+s+on,.,

Domestic Mail Only
ri
Ln � O EF'Wl, 2M I pry"
r� Postage') - — I f418t-I
Ir 1. lg
Certified Fee 'l CI. DO
r-I 0 Postmark
t3 Return Receipt Fee Here
t7 (Endorsement Required)IM
Restricted Delivery Fee
O (Endorsement Required)
ti $CI
Q' Total Postage & Fees $ 12/I (1 /201 6
o $6. —
L n Sent To f W1
rl - Wl------- IqL-~----- -- ------�-�':' -•
vraol�l�
t7 Street R Apt. No.,
or PO Box No.
City, State, ZIP+4���CA t44 O W
■ Complete ttflms 1, 2, and 3.
■ Print your nam9 and address on the reverse
so that we can retum the card to you.
■ Attach this card to fhe.back of the malIPiece,
or on the front if sflace Rwm ts. .
1. Arfide
*1�h
a�a moo�
Illilllli III Illilll IIIIIII III IIII ii III III III
9590 9402 1589 5362 5046 44
A. signature
,�
0 Addressee
B. R C. Date !3 03 /
D. Is de Nery address different from ftem 1? ❑ Yes
If YES. enter delivery address below. p No
3. Service Type ❑ RWty Mad Express®
❑ A" Signah- ❑ RegWtared MaNTM
Sigrreture Resbicbad DeNvety ❑ Reglstetad Mad Resbicted
❑ CertlRed h7lall peetricted Ow" ❑ Retum Rsodpt for
r, . n.s,.e... Merchar dise

Its p(t'/Y a�'.
eghg,;� r
j uArl t
CP (#-,7 mid-�p7l