67954D - Gosney

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NC Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant: L 0 $ V-e\ /
Date: �2/L .1 A b ( ('
Permit #: �-7 q s -H-
Describe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
Found in your Habitat code sheet.
-labitat Name
DISTURB TYPE
Choose One
TOTAL Sq. Ft FINAL Sq. Ft.
(Applied for. (Anticipated final
Disturbance total disturbance.
includes any Excludes any
anticipated restoration
restoration or and/or temp
temp impacts) impact amount
TOTAL Feet
(Applied for.
Disturbance
total includes
any anticipated
restoration or
temp impacts)
FINAL feet
(Anticipated final
disturbance.
Excludes any
restoration and/o
temp impact
amount
I�
Dredge ❑ Fill K Both ElOther ❑
l v
D D
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 Q Other ❑
Dredge 0 Fill ❑ Both ❑ Other ❑

Payment Proccessing Confirmation
Date Received 12/8/20161
Check From (Name) Maritime Coastal Construction LLC
Name of Permit Holder Dennis Gosney
Vendor CresCom Bank
Check Number 2376
Check amount $400.00
Multiple Permits No
Major/Minor
Permit Number/Comments GP 67954D
Receipt or Refund/Reallocated SF/2847D

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit:
Mailing Address:
T
Phone Number: 2 2-1— /&'T
Email Address:
I certify that I have authorized
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: ey 7&-7V-c 41,0, ' rIf- ,6�/, Oea
at my property located at �r
in ,,C—Mk14'c:. County.
1 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 information related to this
permit Application.
Owner Infonnation:
Oeollr Si ature
j S rD 5h
Print or Type Name
Title
Date

HANU UtLIYtK
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to �:_:.h t S 6 6 S /t G� 's
(tame of Property Owner)
property located at 410
(Lot, Block, Road, etc.)
on in , tit r► S Cf— tU e4 c N.C.
(Waterbody) (Town and/or County)
Applicant's phone # - I Oct' �" Mailing Address: eo 'JOx `b
y0 0 7 /Ylo� o eyd1 ���
He has described to me, as shown below, the development he is proposing at that location, and, I
have no objections to his proposal.
DESCRIPTION AND/OR DRAIVING OF PROPOSED DEVELOPMENT:
{To be filled in by property owner proposing develop»rent)
(information for Property Owner Applying
(Riparian Property Owner Information)
for Permit)
Mailing Address(
Ale-
1 /� Signature
City/State/Zip
Print or Type Name
70y-- aaj- 400 7 7� 06og

APS.com® - USPS Tracking®
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Tracking Number: 70151520000241871886
On Time
Updated Delivery Day: Monday, December 5, 2016
Product & Tracking Information
Postal Product: Features:
First -Class Mail" Certified Mail' Return Receipt
See tracking for related item: 9590940220216123293133
DATE & TIME STATUS OF ITEM LOCATION
December 5, 2016 , 1:56 Delivered, Left with LAURINBURG, NC 28352
pm Individual
Your item was delivered to an individual at the address at 1:56 pm on December 5, 2016 in
LAURINBURG. NC 28352,
December 5, 2016, 9:44 am
Out for Delivery
LAURINBURG. NC 28352
December 5, 2016, 9:34 am
Sorting Complete
LAURINBURG, NC 28352
December 5, 2016, 7:00 am
Arrived at Unit
LAURINBURG, NC 28352
December 5, 2016 , 2:29 am
Departed USPS Facility
FAYETTEVILLE, NC 28302
December 3, 2016 , 7:44 pm
Arrived at USPS Facility
FAYETTEVILLE, NC 28302
December 3, 2016, 8:56 am
Departed USPS Facility
CHARLOTTE, NC 28228
December 3, 2016 , 3:15 am
Arrived at USPS Facility
CHARLOTTE, NC 28228
December 2. 2016, 4:38 pm
Departed Post Office
SHALLOTTE, NC 28470
December 2. 2016, 3:52 pm
Acceptance
SHALLOTTE, NC 28470
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AGUSPS.COM
USPS Tracking
Tracking Number: 70151620000241871886
On Time
Updated Delivery Day: Monday, December 5, 2016
Product & Tracking Information
Postal Product: Features:
First -Class M9118 Certified Mali'"' Return Receipt
S" tracking for related Item:
9590940220216123293133
DATE & TIME STATUS OF ITEM LOCATM
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December 5, 2016, Delivered, Left with
1:56 pm Individual LAURINBURG, NC 28$52
Your item was delivorad to an individ(A at the address at 1:56 pn-i on 5, 2016 ill
LAURINSURG. NC218352. -
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