69256D - Longenecker

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Implete items 1, 2, and 3.
nt your name and address on the reverse
that we can return the card to you.
ach this card to the back of the mailpiece,
on the front if space permits.
cle Addressed to: nn
C�� 3y S�u►�r:� 21+11e.,
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1111111111111111111111111111111111 IIII II III
9590 9403 0319 5155 0732 08
article Number (Transfer from service label)
„J16 2140 0000 0834 8426
Form 3811, April 2015 PSN 7530-02-000-9053
■ 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.
I. Article Addressed to:
JI � W SCk
A.
X ` _ \ ❑Agent
\`� Addre
Received by (Pnn Name) � C. Dat DeL
If YES, enter delivery address below: ❑ No
3. Service Type
❑ Adult Signature
❑ Priority Mall Expresso
❑ Adu lt Signature Restricted Delivery
Certified
❑ Registered Mail-
❑ Registered Mail Restricted
Mail@
0 Certified Mail Restricted Delivery
Delivery
❑ Return Receipt for
❑ Collect on Delivery
Merchandise
❑ Collect on Delivery Restricted Delivery
❑ Signature Confirmation-
0 Insured Mail
❑ Signature Confirmation
Mail Restricted Delivery
Restricted Delivery
DO)
Domestic Return Receipt
A, ature
/ r
❑ Agent
13 Addressee
B) Received by (Printed Name) C. Date of Delivery
D. Is delivery address different from item 1? O
If YES, enter delivery address below: ❑ No
II
3. Service Type ❑ Priority Mail ExpressO IIIIIII IIII III I I I I I III III II II i I I IIII I II i I III ❑ Adult Signature 0 Registered MailT
❑ Adult Signature Restricted Delivery ❑Registered Mail Restricted
rs Certified MZO Delivery
959E 9403 0319 5155 0732 15 Certified Mail Restricted Delivery ❑ Return Receipt for
❑ Collect on Delivery Merchandise
A. i,la Kh lmh— (Transfer from service label) ❑ Collect on Delivery Restricted Delivery 0 Signature Confirmation—
^il ❑ Signature Confirmation
7016 2140 0000 0834 8433 ^� it Restricted Delivery Restricted Delivery
'S Form 3811, April 2015 PSN 7530-02-000-9053 Domestic Return Receipt
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NC Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant: �C"t & V-vt eG Permit*
Date: b � h 1 Ih 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.
Habitat Name
DISTURB TYPE
Choose One
TOTAL Sq. Ft.
(Applied for.
Disturbance total
includes any
anticipated
restoration or
tempimpacts)
FINAL Sq. Ft.
(Anticipated final
disturbance.
Excludes any
restoration
and/or temp
impact amount
TOTAL Feet FINAL Feet
(Applied for. (Anticipated final
Disturbance disturbance.
total includes Excludes any
any anticipated restoration and/or
restoration or temp impact
tempimpacts) amount
1 V
v
Dredge ❑ Fill ❑ Both ❑ Other
rnrn
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge [] Fill ❑ Both ❑ Other ❑ .
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill [I Both C] Other ❑
Dredge ❑ Fill ❑ Both ❑ Other 171

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: K?'VIA
Mailing Address: �,D . �6 f 7
9�b /�✓la /1/�i o� � yak ;7
Phone Number: 21 %0-3332
Email Address: 16AO e Z
I certify that I have authorized /giW
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all C)AMA permits
necessary for the following proposed development- A-14 i141F
4 ews41, r),vJ4 4 4v, /,It
at my property located at
in ArHnsivIA 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:
0 tv ,
Title

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner:
Address of Property
vlll lon
-SS'/ 15aJ l ,n d
(Lot or Street #, StreE6 or Road, City && County)
Agent's Name #: 41 /,etJ Mor:te. C40A5
Agent's phone #: 1/0- D-3a -D 53U
Mailing Address: ga g- , 1) 4-
Marn�s�tRJ . /1%G a Yy3
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 ai e proposing. A description or drawing, with dimensions, must be provided with this !otter.
.Vr 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. Contact information for DCM offices is
availableathttp://www.nccoastaimanag inent.netlweb/cm/staff-listin_gorbycalling1-888-4RCOAST.
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, boat ramp, breakwater, boathouse, or lift 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.)
S&�* I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Prop rty Ownition)
Signature
AA
Print or Type Nam
PO 801 / 7
Mailing Address
(Riparian Property nformation)
u
Signature
1�, ? �00 "
Print or Type Name
Mailing A dress