67952D - Fulton

NC Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant:��
Date: JJJJJJ
11
Describe below the HABITAT disturbances for the application.
found in your Habitat code sheet.
Permit #:
All values should match the name, and units of measurement
Habitat Name
DISTURB TYPE
Choose One
TOTAL Sq. Ft.
(Applied for.
Disturbance total
includes any
anticipated
restoration or
temp impacts)
FINAL Sq. Ft.
(Anticipated final
disturbance.
Excludes any
restoration
and/or temp
im act amount
TOTAL Feet
(Applied for.
Disturbance
total includes
any anticipated
restoration or
temp impacts)
FINAL feet
(Anticipated final
disturbance.
Excludes any
restoration and/or
temp impact
amount
Dredge ❑ Fill ❑ Both ❑ Other
\
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑. Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑ .
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both [I Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

3ayment Proccessing Confirmation
Date Received 12/30/2016
:heck From (Name) Ron Kapkonski (Postal Money Order)
Name of Permit Holder Tammy Fulton
Vendor USPS (Money Order)
Check Number 24210400656
Check amount $200.00
Multiple Permits No
Major/Minor
Permit Number/Comments GP 67952D
Receipt or Refund/Reallocated TM/2802D

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: n�/YI /Lt v Ft / a
Mailing Address: �f-O /{� , 4 ey e- `C
Phone Number: 70'�- - ;2 / 3
Email Address:
I certify that I have authorized
Agent /
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 38 5-3 W C Kut u U i e w V v'. Ocil ;via A -e, C),
iCounty.
1 furthermore certify that I 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:
a �7 t-- 140
ignature
I a o n
Pri or Type Name
Title

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to
property located at 3gSs C Lo V-
(Adds
on
(Waterbody)
(Namd of Proper pety Owner)
ul2� f�UJiyia- Ass, Lot, Block, Road, etc.)
in
(City/Town and/or County)
I
2 Z
N.C.
The applicant has described to me, as shown below, the development proposed at the above locatic
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)
1,21-1
12,"t
1z1PWn ?0
Q e—w
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v
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WAIVER SECTION
I Inderstand that a pier, do k, mooring pilings, breakwater, boathouse, lift, or groin must be set bac
minimum distance of 15' from my area of riparian access unless waived by me. (If you wish to wa
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) (Adiacant Property Owner Information)
Signature (..l ature� _
/ OVA) �� _►Printame
oTye N me � or TypeV—
/�
f • �rl�r 9"Sl�k

ll
I hereby certify that I own property adjacent to' -
property located at
(Address
on 6LD (�C�iut`1�'
(Waterbody)
I
(Nanh_%of Prope
Bloc"opd, etc.)
r-X\W� (/\ , N.C.
(City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above location
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
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.)
G 1 do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information) (Ad' nt Property
�Owner Information)
l/l� Lam/
Signature C,Si at e'Oeop
Print or Type Name
ant or Type W69V
��I�'7 ill ea)

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
Name of Property Owner:
Address of Property: J Y S N t h KD t
(Lot or Street #, Stree
Agent's Name #:
Agent's phone #:
16
S/q 2 Z
Road, City & County) y Uyl 5 UJ I C K
Mailing Address:
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 p oposing. A description or drawing, with dimensions, must be provided with this letter.
ave no objections to this proposal. I have objections to this proposal.
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. Correspondence should be mailed to 127 Cardinal Drive Ext,
KriImington, NC, 28405-3845. DCM representatives can also be contacted at [phone]. No response is
considered the same as no objection if you have been notified by Certified Mail.
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.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
Signature
(a rhM
Print or Type Name
Ll09 X, -t3eeee r
Mailing Address
f�
rmation)
Print or Type Name
s ( 66
Mailing Address
Z)