69039D - Knott

an

NC Division of Coastal Mgt. Habitat Impact Com
Applicant: C�
Date:
Describe below the HABITAT disturbances for the application.
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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
tem impacts)
impact amount
ternimpacts)
ar
r 1
D I
Dredge [IFill ❑ Both ElOther K
I>U l
I ( 0
L
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

John E, Skvar la, I
Secretary
AGENT AUTHORIZATION FORM AGENT AUTHORIZATION FQKNI
Date: 9.)
ame of Property Owner Applying for Permit: Name of Authorized Agent for this project:
I rJ ►` t•J 0 t J
lwner's Mailing Address:
': 64G t►.)AT1<1 15 CLIK nr,
tJ.C.
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hone Number CA-Ki.
Agent's Mailing Address:
C IA
Phone Number (V, r ? `?
certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
)r and obtaining all CAMA Permits necessary to install or construct the following (activity):
ke \-kt< 'oc-�e
or my property located at !caG ( t'
'his certification is valid thru (date)
t �T
Property Owner Signature Date

Postal
CERTIFIED a
RECEIPT
Ln a Domestic
a -
ru
SUNSET UACH �, NC 24466,.
CO certrfied nn li Fee t3. 35
$ 0472
m Extra Services &Fees (check box add tea te) 114
Q ❑ Return Receipt (hardcopy) $
Q ❑ Return Receipt (electronic) $ $0. 00 Postmark
Q ❑ Certified Mail Restricted Delivery $ Q Q0 Here
Q ❑Adult Signature Required $--�tl�+--
❑Adult Signature Restricted Delivery $-
C 3 Postage
- $0.49
� Total Postage and Figs.
ees 02/16/2017
$ t6.59
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c rare. �iP+a-------------------
Postal
CERTIFIED. o
RECEIPT
Domestic Mail Only
tti
ra
ru
a0
Certified Mail Fee i3. 3 '
-
`D
m
$
0472
Extra Services &Fees .75
(check box, add fee att
❑ Return
04
O
Receipt (hardcopy) $ •
❑ Return Receipt (electronic) $
Q
❑ Certified Mail Restricted Delivery, $ s[
Postmark
Q
❑Adult Signature Required $
Here
❑ Adutt Signature Restricted Delivery $
Q
Postage tli, 49
$
Total Postage and F
sr. 59
+(2/16/2r(17
p
$
Sent
r
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ref@�P ]Vo.pyoirV/Po�" FLjN
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