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NC Division of Coastal Mgt. Habitat impact Computer Sheet
%ppiicant: V O VA
Date: C7 l /IS 1%o 1-7
Describe below the HABITAT disturbances for the application.
`ound in your Habitat code sheet.
Permit* (,-1ggz-0
All values should match the name, and units of measurement
{abitat Name
DISTURB TYPE
Choose One
TOTAL Sq. Ft.
(Applied .for.
Disturbance total
includes any
anticipated
restoration or
temp impacts)
FINAL Sq. Ft.
(Anticipated final
disturbance.
Excludes any
restoration
and/or temp .
impact amount)
TOTAL Feet
(Applied for.
Disturbance
total includes
any anticipated
restoration or
temp impacts)
FINAL Feet
(Anticipated final
disturbance.
Excludes any
restoration and/or
temp impact
amount
' . 1
O VV
Dredge ❑ Fill ❑ Both ❑ Other
�j
Dredge ❑ Fill ❑ Both ❑ Other El
l ��
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge. [I 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 ❑ Other ❑
Dredge [] Fill ❑ Both ❑ Other ❑ .
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both Other ❑
Dredge ❑ Fill 171 Both ❑ Other ❑

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date
l //20// b
Name of Property Owner Applying for Permit:
1P,3�vid is Lam%
Mailing Address:
I certify that I have authorized (agent) ' to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity) P x do PL/ A
at m property located at / I,,
( Y P P h' ) � �-(� I � S) —yiT?
This certification is valid thru (date)
/1/aa//d
Property Owner Signature
Date

DMSION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORa'vl
Name of Individual Applying For Permit: Uy L �—
Address of Property:
(Lot or Street #, Street or Road)
(City and County)
ere y certify that I own property aTjicent to the above -reference property. The indi,
applying for this permit has described tome as shown on the attached drawing the developmer
are proposing. A description or drawing, with dimensions, should be provided with this let
I
I have no objections to this proposal.
If you have objections to what is being proposed, please write the Division of C
Mana;ement, 127 'Cardinal Drive Extension, Wilmington, INC 28405 or call 910-79(
within 10 days -of receipt of this notice. No response is considered the same as no objec
you have been notified by Certified Mail.
WAIVER SECTION
understand that a pier, dock, mooring pilings, breakwater; boat house or boat lift mus
bck a minimum distance of 15' from my area of riparian access - unless waived by me.
wish to waive the setback, you must initial the appropriate blank below.)
I do wish to waive the 1 5` setback requirement.
I do not wish to waive the 1 5' setback requirement.
YM-I_J a. "'610

LA
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Individual Applying For Permit:��
Address of Property: �zo S�
(Lot or Street #, Street or Road)
� � U �o�-C� - �L1 C— � ►% its
(City and County)
hereby certi that own property adjacent to thewovere erence property. The indi
applying for this permit has described to.me as shown on the attached drawing the developme
are proposing. A description or drawing, with dimensions, should be provided with this lei
LA` I have no objections to this proposal.
If you have objections to what is being proposed, please write the Division of C
Management, 127 'Cardinal Drive Extension, Wilmington, INC 28405 or call 910-79
within 10 days -of receipt of this notice. No response is considered the same as no obje(
you have been notified by Certified Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwoter,.boat house or boat lift mus
bck a minimum distance of 15' from my area of riparian access - unless waived by me.
wish to Nvaive 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 1 5' setback requirement.
I /L--- 1,::2 /C;l / <20
I S km Name Date

th
CV-Jril (4