69040D - Ersele

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NC Division of Coastal Mgt. Habitat Impact Com
Applicant: C I'-l h0 IV) (— t 1
Date: �A a, 1O,6 1�
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
FI
(Applied for.
(Anticipated final
(Applied for.
(A
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
di:
Habitat Name
Choose One
includes any
Excludes any
total includes
E)
anticipated
restoration
any anticipated
re:
restoration or
and/or temp
restoration or
tei
temp impacts)
impact amount
temp impacts)
ar
Dredge ❑ Fill ❑ Both ❑ Other 9�f
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l
Dredge ❑ Fill ❑ Both ❑ Other
Ligo
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge 0 Fill ❑ Both 0 Other ❑

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: / 1' r jc,, h I;sole J-x
Mailing Address:
Phone Number:
Email Address:
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I certify that I have authorized ,k 5"Ia .01
Age / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: '4&Je-k
at my property located at -Yi6b �ear4t% s+r, Ss&j >
in County.
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
69 c.J4-742—t--
Title

■ Complete items 1, 2, and 3.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
Aed to: Address 13
fie,
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A Sig `' / ❑ Agent
by (Printed Na 10. D of
D. Is delivery address different from item Ile
If YES, enter delivery address below: ❑ No
Or
Service Type
❑ Priority Mail Express®
3.
❑ Adult Signature
Restricted Delivery
❑Registered Ma lT"
❑ Registered Mail Restricted
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❑Adult Signature
❑ Certified Mail®
Delivery
❑ Return Receiptfor
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9173 21
❑ Certified Mail Restricted Delivery
❑ Collect on Delivery
Merchandise
0 Signature ConfirmationTM
9590 9402 1911 6104
❑ Collect on Delivery Rest cted Delivery
0 Signature Confirmation
2. Article Number (Transfer from service label)n
in. . H Mail
ail Restricted Delivery
Restricted Delivery
7 016 1370 0000 4730
4690 , ))
Domestic Return Receipt
PS Form 3811, July 2015 PSN 7530-02-000-9053
'
11 A gnat El Agent
■ Complete items 1, 2, and 3. X / ❑Addressee
■ Print your name and address on the reverse �6 C, Date of Delivery
so that we can return the card to you. B. eceiv by (P ' ted Name)
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
_ D. Is delivery address different from item 1? Yes
1. Article Addressed to: If YES, enter delivery address below: ❑ No
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9590 9402 1911 6104 9173 38 '.
_ ... .._._�_- rr.�nclur from service label)
3. Service Type
0 Adult Signature
❑ Adult Signature Restricted Delivery
❑ Certified Mail®
❑ Certified Mail Restricted Delivery
❑ Collect on Delivery
0 Collect on Delivery Restricted Delivery
❑ Priority Mail Express®
❑ Registered Mail"
❑ Registered Mail Restricted
Delivery
❑ Return Receipt for
Merchandise
❑ Signature Confirmation"
❑ Signature Confirmation
Restricted Delivery

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