69245D - Osborne

NC Division of Coastal Mgt. Habitat Impact COMF
Applicant: ANa . 05 66v4�. % ll •rJ.
Date: 00/1 %fib (-
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
FIN
(Applied for.
(Anticipated final
(Applied for.
(An
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
dist
Habitat Name
Choose One
includes any
Excludes any
total includes
Exc
anticipated
restoration
any anticipated
rest
restoration or
and/or temp
restoration or
tern
temp impacts)
impact amount)
temp impacts)
ami
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 ❑

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North Carolina Department of E^vironrT*nt and Natural Resources
N.C. Divisior of Coastal Management
John E.
S(
AGENT AUTHORIZATION FORM
Date
Name of�/Pfroperty Owner Appfy� for Permit Name of Authorized Agent for this progec
Owner's Mailing Address
Ave.
Agent's Malfkrg Address.
I902 K,r 4 Kd
-�-----ni C 2 4 (o Z
Email Ernad
PhoneD7����� —A.4`'q4P . Phone
zerl!fy that I have authorized the agent !tsted above to act on my behalf, for the purpose of applyinc
for. and obtarn►ng all CAMA Permits necessary to install or construct the folloming (activity)
For my property located at

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner /%/(ar-
Address of Property —,2 S 3 $ d 4,..
(Lot or Street a Street or moat l,uy 6
Agent's Name 8 J(c9&Ll--ZE firs pq Mailing Address 1 G
Agent's phone # 9/�-- W 3- �6 1 y , 1 2 Si
I hereby certify that I own property adjacent to the above referenced property. The indivi
applying for this permit has described to me as shown on the attached drawing_the develop,
they are proposing A description or drawmq with dimensions must be provided with this let
vN-14t 4� f I have no objections to this prulx)sai. 1 have objections to this proposal.
N you )eve objections to whet is being proposed, you must noddy the Dhvrsion of Coastal Alanagement DC
wrfting wfth)n 10 days of receipt of this notice. Correspondence shourd be ►netted to 127 t.ardtnat Or(DC KS706gton, NC, 28405-3845. DCM represe,ntadves tan a)so be contacted at [phone]. No respon
considered the samo as no ob oc6on if you have been notified by CortMtd AW1
WAIVER SECTION
I understand that a pier, dock, moonng pilings, breakwater, boathouse, lift, or groin must be 5
back a minimum distance of 15' from my area of riparian access unless waived by me. (if yoi,
wish to waive the setback, you must initial the appropriate blank below)
I do %msh to waive the 15' setback requirement
t I do not wish to waive the 15' setback requirement.
(Property Own Iofh+tati )
Signa)ure
JAdjacgnntyP,rrooperty Owner informatio
SiXnalure

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner
Address of Property
o.
(Lot or Street 0 Street or Koao. Uty 6
_G.
Agent s Name a lam. 1 /� f�S c7c� MailingAddress lJ7 e, I.-,
Agent's phone # !/© y� 3' cS 1 �� .5.,0a-0a I%,.fi/.� c
I hereby certify that 1 own properly adjacent ID the above referenced property. The individua
applying for this permit has described to me as shown on the attached dra-Anng the developmen
they are proposing A description or drawing. with dimensions, must be OrovidW with this letter.
(1,11� 'LCL I have no objections to this prupusal. I have objections to this proposal.
NYOUhave o4OeNons to wAst is b&%g Proposed. You awat notly 11» otvWW oI CossW Afana9omsnt (OCAQ 11
wr1110 wftMn 10 days Of reaNpt of 009 notlte. Correspondents shouts be OmMed to 127 Cardinal Drive Ert
*%W*19100111, NC, 28405-SM. OCM rapnssntatives can also be contacted at [phone] No response i,
tonsidW the pins ss no oblktion N 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 )
(1 �(•l I do msh to waive the 15' setback requirement
C t eAv I do not wish to waive the 15' setback requirement.
(Property Own InSofrrteti )
Signature
(Adjacent Property Owner Information)
6
Signature U 0 NX 1140 wo ki "pebriz

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