69162D - Shottner

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NC Division of Coastal Mgt. Habitat Impact Coml
Applicant: �D Sh
Date: 6 t /3 ' /a �� l
Describe bellow 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
FIP
(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
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 ❑

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: 7 u Sr�o
Mailing Address: q35,5
Phone Number:
Email Address:
certify that I have authorized _ 13� aoc\ Mj-t c� Loc
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:o��
at my property located at 14 -7 v.ar\ 0�-- -D11 4t� A-* n 6-- ,
in �� w;►S rJ County.
I furthermore certify that / 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:
U�."AIX
SI ature /
Print r Type Name
OW ��
Title
41 1 -:� I i-7

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner: o n
J
Address of Property: l ��, �„ �� 1 � l��
`6
(Lot or Street #, Street or Road, City & County)
Agent's Name #:k2����_
Agent's phone #: _°�I L l
Mailing Address: 50ca, at �A Q.t
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 what is being proposed, you must notify the Division of Coastal Management (DCM) in
writing within 10 days of receipt of this notice. Correspondence should be maited to 127 Cardinal Drive Ext,
Wilmington, 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 Mal!
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set
back a minimum distance of 15from my area of riparian access unless waived by me. (If you
wish to waive the setback, you must initial the appropriate blank below.)
do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Prope Owner Information)
Signature
Print or Type N e
Mailing Address
tAdiacRnt propst"iy Ow r atlon)
Signature
Print or Type Name
Mailing Address

�r
M
CERTIFIED MAIL - RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
Name of Property Owner:
Address of Property:
(Lot or Street #, Street or Road, City & County)
Agent's Name #:� ',aZ PNurL,�- Mailing Address:
Agent's phone #: �! ��i� o n L nn-> as lam
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 what is 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.,
Wilmington, NC, 28405-3845. DCM representatives can also be contacted at (910) 79&7215. 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)
Signature
Sh r
Print or Type NAbe
ggt3,! `fro ec-%Aaee� �)Jecsccl
AJn;U iv AAilr.. e.n
(Adjacent Property Owner Information)
Signature
—r--u iso
BqAs
Print or Tyo Name
t i._.ak0- ;T, et,:�

■ Complete Items 1, 2, and 3. A. Aeceived
■ Print your name and address on the reverse El Agent
so that we can return the card to you. ❑ Addressee
■ Attach this card to the back of the mailpiece, B. by (Printed Name) C. Date of Delivery
or on the front if space permits.
1. Article Addressed to:
D. Is delivery address different from item 1? ❑ Yes
If YES, enter delivery address below: ❑ No
APR - 6 'Z01 i
Service Type
Adult Signature
❑ Priority Mail Express®
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d Adult Signature Restricted Delivery
❑ Registered Maur"
❑Registered Mail F
9590 9402 1912 6104 4507 42
Certified Mail®
0 Certified Mail Restricted Delivery
Delivery
❑ Return Receip'
❑ Collect on Delivery
Merchandise
2. Article Numhor rr-4 -�-- __._.•_ .. .•
7 015 1520 0003 2854
— lelivery Restricted Delivery El Signature Confin
1] Signature
2111 re Dori m
„ Restr cted Delivery
(overelivery
$500)
Restri
PS Form 3811, July 2015 PSN 7530-02-000-9053
Domestic Return Receipt
HERDERSQN r, NC 27536
srtified Mail Fee
$3.35 Ii4F: p.
dra Services & Fees (check box, add hee a o date) t� LQ
9-
] Return Receipt (hardcopy) $ $
] Return Receipt (electronic) $ Postmar
]Certified Mail Restricted Delivery $ -�...LL Here
] Adult Signature Required $ _tiiia
] Adult Signature Restricted Delivery $ 7 V V 00
ostage $0.49 G J Li
otal Postage and Fees
�b.59
lent To Ir
street and Apt No., or PO 10 No.
�3 0 L kev�- e-j z-) =
;ty �rate4�4 z.,,
■ 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.
U.S. Postal Service'"
CERTIFIED MAID° RtCE(PT
-• Domestic Mail Only
For delivery information, visit our website at www.usps.come.
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❑ Agent
ieceivecTby (PrinteAName) C. Da o Delivery
D. Is delivery address different from item 1 ? ' [T Yes
1. Article Addressed to: