69276D - Ezzell

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to Z PZ7_e— (( s
vl property located at f fOQerty Qyur)
(Address, Lot, Block, oad, 'N N
on , in , N.C.
(VAterbody) (City/Town and/orCounty)
The applicant has described to me, as shown below, the development proposed at the above
location.
i� �c 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, boat ramp, 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) (Adja ent ProperttyOwner Information)
Signatu^r S' ature* t
Z CLL�I I�cbC:� �11,�c('iS—�ccvnc�
Print or Ty a Qom f ' Print or Type N e

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to
9 property located at D Db
94
(Address, Lot,
on C rn , in
(W erbody)
k Z EZZe. I I 's
(N e✓ Pr,eA<A OvN;
(City/Town and/or
N.C.
The applicant has described to me, as shown below, the development proposed at the above
tacation. ; -"
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)
9 % J o
WAIVER SECTION
c
I understand that a pier, dock, mooring pilings, boat ramp, 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 w'sh 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) 77ent Property O!wnA Informatio )
Signptweeo,
�Z� � � Signature*
Z . I \
Pri►�t �or`Ty�e me rent Name
AAa&nn AWrlracc AA —;I;.__ n��____

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: - 7-1. 2—
Mailing Address:
Phone Number:
Email Address: 9AE111 .Z2,c- �� :,4, 6,
I certify that I have authorized C-,� ,.'/P-G% s1
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 %7o ou 0/
in O County.
l 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:
c,,O,,� -�h (::�"/
Signature
Print or Type Name
Title
/ / /z2

NC Division of Coastal Mgt. Habitat Impact Coml
Applicant:Cj[i
Date:—
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
Fll�
(Applied for.
(Anticipated final
(Applied for.
(An
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
disc
Habitat Name
Choose One
includes any
Excludes any
total includes
Exc
anticipated
restoration
any anticipated
rest
restoration or
and/or temp
restoration or
terr
temp impacts)
impact amount)
temp impacts)
am,
Dredge ❑ Fill [IBoth [I Other
D
Dl�
Dredge ❑ Fill ABoth ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑