69012D - Hudson

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■ 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.
1. Article Addressed to:
l� 11 i am NudsLA
359D Pit& I_.opil R�.
5�(�
A. Signature
❑ Agent X
/ ❑ Addressee
B. Received by (Printed Name) C. Date of Delivery
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D. Is delivery address different from item 1? ❑ Yes
If YES, enter delivery address below: p No
3, Service Type
❑ Priority Mail I 0
❑ Adult Signature
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❑Registered MaiIT"'
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III II
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III III
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❑ t Signature Restricted Delivery
❑ Registered Mail Restricted
ertified Mail®
Rlelivery
for
9590 9403 0319 5155 0382 52
❑ Certified Mail Restricted Delivery
E+f Retur�pt
❑ Collect on Delivery
on Delivery Restricted Delivery
❑ Signature ConfirmationT
7 015 1520 0 0 0-2 2209 9636
Mail
Mail Restricted Delivery
❑ Signature Confirmation
Restricted Delivery
(over$500)
PS Form 3811, April 2015 PSN 7530-02-000-9053
Domestic Return Receipt
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NC Division of Coastal Mgt. Habitat Impact Cow
Applicant: �,. ., V� Lb
Date: 6
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
to
ternp
im act amount
temp impacts)
ar
1 v\
Dredge ❑ Fill ❑ Both ❑ Other v
impacts)
3 v U
-3Q v
ODredge
❑ Fill ❑ Both ❑ Other
2 `o O
2- 0
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

HAND DELIVER
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIE IMOORING PILINGSBOATLIFTIBOATHOUSE)
I hereby certify that I own property adjacent to l)1(1 t 6 n" - [Ltj S w) 's
(Name of Property Owner)
piopci-ty located at �Q o 2_CCr 1— t/�,i h /— I/e V� �. c1►
(Lot, Block, Road, etc.)
on - — `--L V , in - t.'A (._ K- , N.C.
(Waterbody) (Town and/or County)
Applicant's phone k:(%'1Z Mailing Address: i O Pt n-I
c OaL-u s��`t 112
He has described to me, as shown below, the development he is proposing at that location, and, I
have no objections to his proposal. I understand that a pier/mooring pilings / boatlift / boathouse
must be set back a minimum distance of fifteen feet (I 5) 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 42.ng wish to waive
I do wish to waive that setback requitement.
---- ---- ------------------------------------------------------------------
DESCRIPTION AND/OR DRAWING OF PROPOStD 0EVELOI'1ViEN`I':
(To be filled in by individual proposing development)
(Information for Property Owner Applying
for Permit)
-1-10 P� J-c Lcry,-t(n Cl 0-
oG d
Mailing Address
(Riparian Property Owner Information)
-Jzz�-
I SignAture

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
Name of Property Owner: i,,Li i (l t G
Address of Property: av T
(Lot or Street #,,Street or Road, City & County)
Agent's Name #:
Agent's phone #:
Mailing Address:`
TZ
I hereby certify that I own property adjacent to the above referenced property. The individual
applying for this permit has described to me as shown on the attached drawing the development
they are proposing. A description or drawing with dimensions must be provided with this letter.
I have no objections to this proposal. I have objections to this proposal.
If you have objections to what is being proposed, you must notify the Division of Coastal Management (DCM) in
writing within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive Ext.
Wilmington, NC, 28405-3845. 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
WAIVER SECTION
I understand that a pier, dock, mooring pilings, 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.
(Prop rty Owner Information)
Si a re
LA ) l ) ( 16n-) 41 �� S
Print or Type Name
(Adjacent Property Owner Information)
Signature
112L L.) - -I t cLJ
Print or Type Name
Mailing Address
Mailing Address

U.S.
Postal
Service'"
CERTIFIED
Domestic
Mail Only
MAIL°
RECEIPT
For delivery
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❑Return Receipt (hardcop�f
0 $-
O ❑Return Receipt (electronic) $ 17. 1 III I
O ❑Certified Mail Restricted Delivery $ - POStmark
O ❑ Adult Signature Required $-- Here
10 Adult Signature Restricted Deltvm
l� stage Pov $ ` - -- -
,2- $
M Total Postage and F e�"— -- (I5 /fl'! o $ ? .11 /2016
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