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NC Division of Coastal Mgt. Habitat Impact Coml
Applicant: �v� R �j/$S 1 .
Date: d q/0 t, 06
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
Fit
(Applied for.
(Anticipated final
(Applied for.
(An
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
disl
Habitat Name
Choose One
includes any
Excludes any
total includes
Exc
anticipated
restoration
any anticipated
res
restoration or
and/or temp
restoration or
ten
temp impacts)
impact amount)
temp impacts
am
vV
Dredge ❑ Fill ❑ Both ❑ Other
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Dredge ❑ Fill ❑ Both ❑ Other
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: I—Omt5 P. ` 1 U SS
Mailing Address: 5 51 L &e(4q C-k 5Q
a can S le- geCLC_� , N C a %y
Phone Number: 9 la - -75 y - 5 10-1
Email Address: ORU SS ® RTrn G. N E T
I certify that I have authorized .1 An i e � Rysi
,
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: Re - +uey"kS
e $jfvxj CLjWcjrj (Sfi
at my property located at 5 514 8,e(4kq Ct SO; 0T6 cc as% ,
in 6(un5ui c�— County.
I furthermore certify that 1 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:
12,E
U Signature
FoAles P RUSf
Print or Type Name
TWO

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to J arY1-eS P Rvsf s
property located at 5574 &Acl C4- 5W�Q 0 (Name of Property Owner)
N C 'd$4 �k `1
on �nirarogs(Address, Lot, Block, Road, etc.)
� ���f�wa�/ , in Ocfot%- 4eu.ck,NC BrunSwictG , N.C.
(Waterbody) (City/Town and/or County)IL0111%4-5
The applicant has described to me, as shown below, the development proposed at the above locatic
X I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set bac
minimum distance of 15' from my area of riparian access unless waived by me. (If you wish to wa
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 15' setback requirement.
(Property Owner Information)
P (&,-
Si nalure
Tames Russ
(Adjacent Props caner Information)
�ignalure
')eYnor's Nelms
Print or e Name
SS�lTyp4 Swoe16r.
Print or Type Name
S4I4 1 rJ P,,(, n- c..,

CERTIFIED MAIL - RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner: Tm-es P RA SS
Address of Property:
5514 B-e(AcA C+. SW , occah Tsle Gatti , NC Wta l
(Lot or Street #, Street or Road, City & County)
Agent's Name #:
DAnie ( R U63
Mailing Address:
g(OOa�-I gtuCN
Or 5 w
Agent's phone #:
�1W
�llo
/� g 'a�.3 (�
�cec4r� TS1e
rJectc.k, W
ag q (D 1
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 are proposing. A description or drawing, with dimensions, must be provided with this letter.
I have no objections to this proposal. _ I have objections to this proposal.
If you have objections to whatis being proposed, you must notify the Division of Coastal Management (DCM) in
writing within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive Ext.,
Wifmington, NC, 28405-3845. DCM representatives can also be contacted at [phone]. 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, 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.)
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
'Property Owner Information) (Adjacent Property Owner Information)
rgnature
i
Jnrn�s P Rvss
'Tint or Type Name
5 5 -1 `i ge4v\oq C+ SW
Signature
Print or Type Name
flailing Address Mailing Address

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SOUTH BRUNSWICK
1587 SEASIDE RD SW
OCEAN ISLE BEACH
NC
28469-1029
3669930470
11/29/2016 [phone] 9:41 AM
Product Sale Final
Description oty Price
First -Class 1 $0.47
Mail
Letter
(Domestic)
(WILMINGTON, NC 28401)
(Weight:0 Lb 0.80 Oz)
(Expected Delivery Day)
(Thursday 12/01/2016)
Certified 1 $3.30
� t@@USPS Certified Mail #)
(70150920000076078978)
Return 1 $2.70
Receipt
(@@USPS Return Receipt #)
(9590940302355146986554)
Total -
$6.47
Cash - - - -
.00
'hangs ($0.53> 0.53)
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