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Home My WebLink About69038D - Reed NC Division of Coastal Mgt. Habitat Impact Com Applicant: Date: 03��d/�o1 7 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 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 tei tem im acts) impact amount ternimpacts) an NDredge ❑ 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 ❑ ; Ar i�� NCDENR North Carolina Department of Environment and Natural Resources Division of Coastal Management Pat McCrory Braxton C. Davis John E. Skvar Governor Director Secretar AGENT AUTHORIZATION FORM AGENT AUTHORIZATION FUKM Date: I of v12 11 (a Name of Property Owner Applying for Permit ERS ORerb Owner's Mailing Address: A45:5 M"& Aie SF Ile�wc, wR '18005 Name of Authorized Agent for this project: rice Cons�rtkc+h on Agent's Mailing Address (p(pIg'gCAA'7DrIVC ,SW Ocep6A 13le 3C44A , NC 2b4le Phone Number (20L) 04 - 2515 Phone Number 10 11_ I certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to install or construct the following (activity): For my property located at 57 1 M 11 This certification is valid thru (date) Property Owner Signature Date 0.CA . N L CERTIFIED MAIL -.Rg,TURN RECEIPT REQUESTEt� -DIVISION OF COASTAL MANAGEMENT ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM �� ' i �eec� - Name of Property Owner: Q _-------_- _ Address of Property: S W I1 �nf11 n_ 3_0 �a Ta1�_4C ------ (Lot or Stre , Street or Road, City & CounFyT Q Agent's Name #: V C 1(A `�"�'n5� �� 1 J n Mailing Add(� Address: 0_` 1.�2�1C� t "rs3 Agent's phone ll: c;1b-51°l-�� ( 15�Q QuC31 N� ZIAi 1 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 are proposing. 1 have uo objections to 111is propostll. _ __ I have ot�jeetions to this propostll. If you have objections to what. is being proposed, you must notify the Division 'of Coastal Manage►nent (OCM) In writing within 10 days of receipt of this notice. CorrespQn{lence.shauld be mailed to 127 Cardinal Drive Ext., Wilmington, NC, 28405-3845. DCM represent4olves can also be contacted at (910) 796-7215. No response is considered the same as no objection if you hVo been notified by Certified Mall. WAIVER SECTION I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin mast 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.) I do wish to waive the I6' setback requirement. I do not wish to waive the 15' setback requirement. (Propert Ow or Information) (Adjacent Pr Orly Owner Information) Si�nnlrrr•e Print or Type Namo Print or Type Name V2 Mulling Addre;ss Mailing Address Crryistw&e 1p C►tyistat 'telephone Number Telephone Number �qlaQ WN-Cq i(� same l�� V�-; C�'r I � 1,.,0.u�y W ►�� iO►''m,S ■ Complete items 1, 2, and 3. A. Signature ■ Print your name and address on the reverse X� so that we can return the card to you. B. Receive ■ Attach this card to the back of the mailpiece, or on the front if space permits. 1. Article Addressed to: / ❑ Agent �—' ❑ Addressee by (Ifirlted Name) C. Date of Delivery D. Is delivery address different from item 1? ❑ Yes If YES, enter delivery address below: ❑ No II I'III'I I'II I�I I I I I I I I III II I II I I I I I I III 3. Service Type ❑ Priority Mail Express(D fJ Adult Signature ❑Registered MaiIT'" ❑ Adult Signature Restricted Delivery ❑ Registered Mail Restricted 9590 9403 0603 5183 4329 67 IOGertified Mail@ Delivery ❑ Certified Mail Restricted Delivery PlIelurn Receipt for ❑ Collect on Delivery Merchandise 2' T anc ^ "r, •far frnm service label) El on Delivery Restricted Delivery El Signature Confirmation— �' .-.t,e- re,il ❑ Signature Confirmation 7 015 0-6 4 0 0006 3682 2482 lestricted Delivery Restricted Delivery PS Form 3811, April 2015 PSN 7530-02-000-9053 Domestic Return Receipt Domestic Mail Only Er Q Domestic • r delh7ery information, visit our website at wwmusps.coml. RALEI GH Y, NC' 2^ 7,rU ti For delivery information, visit our website at �30S Mr NC3L www. usps.cIni ,ertified Mail Fee 114�I1 ' 1'127 Certified Mall Fee ; J• J`I [147a ? �xtra Services & Fees (check box, add fee a te) ? I ❑ Retum Recelpt (hardcopy) $ ".0 M $ Extra Services & Fees (check box, add fee amp 1 i ❑ Return Receipt (electronic) $i I I . i I I I Poste* ,� C:3 ❑Return Receipt (hardcopyl $ f-. ❑ Return Receipt (electronic) $ 4iI 1 _ 110 Poebriark ❑ Certified Mail Restricted Delivery $ dal I i i 1 _ Here 0 ❑ Certified Mail Restnctad Delivery $ Q 1� Here ❑ Adult Signature Required $$0.00� ❑ Adult Signature Restricted Delivery $ ❑ Adutt Signature Required $ _ 'ostage ❑ Adult Signature Restricted Delivery $ I I " 47 Postage 1.47 I.14/I I$/7111� 'otal Beet— .7d Fg p � � F Total Postage and 09/08/2016 $ 4 .47 lent To t. iPb oxNo.� rq p- $ Sent --_-_-______________________________ Ste, ZIP �.+� (39 ----------------------------------- ty, fate, ZI `v V S Form 380,', April I15 PSN 7530-02-000-9047 See Reverse for Instructions PS Form :rr April 2015 SENDER:• •N COMPLETE THIS SECTIONON DELIVERY ■ Complete items 1, 2, and 3. A. Signa ■ Print your name and address on the reverse X A ertt so that we can return the card to you. iicessee ■ Attach this card to the back of the mailpiece, Ived by rinte m Date 0i llvery or on the front if space permits. rn 1 Arti^lo LHH, .H to n Vne