67938D - Price

NC Division of Coastal Mgt. Habitat Impact Coml
Applicant:
Date: I k /Z L `l (s
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.
(An
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
dist
Habitat Name
Choose One
includes any
Excludes any
total includes
Exc
anticipated
restoration
any anticipated
rest
restoration or
and/or temp
restoration or
tern
ternp impacts)
im% amount
tem impacts)
amp
rI /
W
Dredge ❑ Fill ❑ Both ❑ Other
` `
/ad
l IQ
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

'ayment Proccessing Confirmation
)ate Received 1 11/23/2016I
:heck From (Name) Willie Clarence Richardson
DBA Richardson Construction
flame of Permit Holder Bob Price
✓endor BB&T
'heck Number 6560
heck amount $600.00
Multiple Permits Yes
Major/Minor
3ermit Number/Comments GP 67938D ($200)
Zeceipt or Refund/Reallocated SF/2844D

WmAj
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue James H. Gregson Dee Freeman
Governor Director Secretary
AGENT AUTHORIZATION FORM
Hate: / I — Pf — I (o
Name of Property Owner Applying for Permit: Name of Authorized Agent for this project:
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Owner's Mailing Address: Agents Mailing Address:
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Phone Number (33b) -Phone Number (9 0 Z%7 — O3 �
I certify that i have authorised the agent listed above to act on my behalf, for the purpose of applying
for and obtaining all CAMA Permits necessary to install or construct the following (activity):
(my property located) at (3 of ' R (3d e, ' 1
This certifi on is lid thru (date)
iiis/,�
Property Owner Signature Date

CERTIFIED i%UL — RETURN RECEIPT REQUESTED
DIVISION OF COASTAL INLA.NAGENIENT
ADJACEs t-T RTPARLA-1i PROPERTY OWNER STATU ENT
I hereby certify that I own property adjacent to Bob 2r, ram-.- 's
(dame of Property Owner)
property located at (3 •'-jj-
(Lot, Block Road, etc.)
on C_c�Ylu l , in t- of CK;Y1 auA-1 , N.C.
(Waterbody) (Town and/or County)
Applicant's phone #: 336 — 1 `-3 — % 8 Mailing Address: 40, q 01- ,
Hylct. n C-1) , K C; A 8 4-6
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 fdl in description below or attach a site drawing)
5+C%,W Cy) 0+ 1 v K :z i iq
u yUU nave ODJeCUOOS TO wnat is being proposed, you must notify the Division of Coastal Management (DOM) in writing
within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive Est Wilmington, NC
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
F
er t1oIl)
Signat
Print or Type Name
3a35 Zlacyeat Yc?
MailingAddress
N Cis
2iparian Property Owner information)
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S g ature
Print or Type Name
(y`-(
Mailing Address

CERTIFIED MAIL — RETURN RECEIPT REOL-ESTED
DIVISION OF COASTAL T1yLkNAGEMENT
ADJACENT RIPARL—k PROPERTY OWINER STATEMENT
I hereby certify that I own property adjacent to b ?n
property located at
(��tame of Property Owner)
� ;�;� ''� � ��a � �� ,5.�
-J (Lot, $lo Voad, etc.)
on OAna. , in � 160a—IJ , N.C.
(Waterbody) (Town and/or County)
Applicant's phone 5 — ? - 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 ANUOR DRAWING OF PROPOSED DEVELOPMENT:
(Xndividual proposing development must fill in description below or attach a site drawing)
4 ( D Y\ baA l4
If you have objections to what is being proposed, you must notify the Division of Coastal'Management (DC1II) in writing
within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive EA Wilmington, NC
DCM representatives can also be contacted at (910) 796-72I5_
No response is considered the same as no ohiectlon ifYou have been notified by Certified Mail
fPrtrpe` ne information) (Riparian Property Owner Information)
a
� t
Signature
Punt or Type Name Print or Type a.me
31�135 ^Quest 'c_ � 5LO3 QI& Fey-±*-Lemnec,
Ivfailing Address Mailing Address
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