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NC Division of Coastal Mgt. Habitat Impact Comr
Applicant:
Date: 11
Describe below the HABITAT disturbances for the application.
All values should match the name, and units of measurement found in your Habitat code sheet.
TOTAL Sq. Ft.
FINAL Sq. Ft.
TOTAL Feet
FIN
(Applied for.
(Anticipated final
(Applied for.
(Anl
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
dish
Habitat Name
Choose One
includes any
Excludes any
total includes
Exc
anticipated
restoration
any anticipated
rest
restoration or
and/or temp
restoration or
tem
tem impacts)
impact amount)
temp im acts
amc
r
�t r
Dredge ❑ Fill 4 Both ❑ Other ❑
3 110
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: /v�ir►� �of�%n
Mailing Address:-g'/c5� �5iioRc�ii c �!� Guc
Phone Number:
Email Address:
I 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
in A i2w�ulc County.
P- s� Je�l
I 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:
Signature
Print or Type Name
0,�4,111ek
Title

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Domestic
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For delivery information, visit our website
at www.usps.com"'.
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$I I, 00
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Certified Fee
Return Receipt Fee
Postmark
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$� �#
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(Endorsement Required)
Restricted Delivery Fee
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(Endorsement Required)
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$I I ,
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Total Postage & Fees
11 /23/201 b
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or PO Box No.
Postal
CERTIFIED tJ RECEIPT
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Domestic Mail Only
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Certified Mail Fee $ . �� (
0470
0
$ 2. 7 it
11
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EXtra Services & Fees (check box, add fee p�r"te)
❑ Return Receipt (hardcopy) $ r-��t?1 -
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❑ Retum Receipt (electronic) $ m • f fry
Postmark
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❑ Certified Mail Restricted Delivery $ I I I l�
Here
❑Adult Signature Required $ $l0T0 tt
❑ Adult Signature Restricted Delivery $
Postage $ 11, 4 7
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$
11 /?3/2016
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Total Postage and Flies` 4 7
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Sent To
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Street and Apt. No., or b Box N
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