69377D - Johnston

Applicant: j 0re
Date:
NC Division of Coastal Mgt. Habitat Impact Com
A 3 oleo, sVzo
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
FII
(Applied for.
(Anticipated final
(Applied for.
(Ai
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
dis
Habitat Name
Choose One
includes any
Excludes any
total includes
Ex
anticipated
restoration
any anticipated
re;
restoration or
and/or temp
restoration or
ter
temp impacts)
impact amount)
temp impacts
an
Dredge ❑ Fill Both ❑ Other ❑
l
l O
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

■ Complete items 1, 2, and 3. A.
■ Print your name and address on the reverse X
so that we can return the card to you.
■ Attach this card to the back of the mailpiece, B.
or on the front if space permits.
1. Article Addressed to:
lu\3 �� �- ��err► L�� t�� 1 �cl
❑ Agent
by (Printed Name) ' I C. Date of Delivery
D. Is delivery address different from item 1? ❑ Yes
If YES, enter delivery address below: ❑ No
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Delivery
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Return Receipt for
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Merchandise
2. cen/iro. lahnll
❑ Collect on Delivery Restricted Delivery
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7 017 0660 0000 7487
2461 restricted Delivery
❑ Signature Confirmation
Restricted Delivery
PS Form 3811, July 2015 PSN 7530-02-000-9053
Domestic Return Receipt
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iery information, visit our website at www.usps.com"". -I- For delivery information, visit our website at www.usps.co
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es & Fees (check box, add fee i l � $ y 1
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celpt (hardcopy) $ - ` te) ❑ Return Receipt (hardcopY) $ I • '= ='
celpt (electronic) $ + _i
Postmark O ❑Return Receipt (electronic) $ Postmark
Ball Restricted Delivery $ '$ i _ (ii I Here 0 ❑ Certified Mail Restricted Delivery $ Z jj fi st Here
iature Required $mot ;--i +-^ 0 ❑ Adult Signature Required $
iature Restricted Delivery $ C3 ❑ Adult Signature Restricted Delivery $
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Il 4 Postage _ u6/22/2017 -B $
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'\\ S t To
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State,
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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 ma)pi
or on the front if space permits. j' p��.�a U
A. Signature
X ❑ Agent
❑ Addressee
B. Received by (Printed Name) I C. Date of Delivery
1. Article Addressed to: j
D. Is delivery address different from item 1? 0 Yes

:=���
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
'at McCrory Braxton C. Davis
Governor Director
John E. Skvarla, III
Secretary
AGENT AUTHORIZATION FORM AGENT AUTHORIZATION FuKM
Date: ©b Z 1-2-014
ime of Property Owner Applying for Permit: Name of Authorized Agent for this project:
A r )nh igsto Gr i cc Cons uc -ie�,
vner's Mailing Address:
f kes be-o, N c Zg('.g-}
one Number f 3N 461- --7fl to (e
Agent's Mailing Address:
(o (o ► 8 aeacti Dr S LJ
OGeon 151e- Beet , NC.
Z 84(aq
Phone Number (qLo) 5�- 9 - RD�i
:rtify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
and obtaining all CAMA Permits neces ary to ins all or constr ct the following (activity):
r my property located at 1411 q(u 61)-eet , Sun Se% Bwtd, N 2-'aloV
s certification is valid thru (date)kkI&
roperty Owner Signature Date

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