68096D - Simmons

4/26/2017
Money order
Mark & Maria
North
360505008
$300.00
GP 68096
from John
Simmons
American
Cassidy
Banking
PO
4/26/2017
Money order
As above
As above
360505009
$300.00
/
from John
Cassidy

NC DiVISIOn O h�V ��J� i'.!�!�{6s 9AGlllJriva ar�alewr—
-
nn
Applicant: flC v 1Gl lr l `e �2 D Vts
Date:.
- Describe below the HABITAT disturbances for the application.
e,.anc units- of measureent found in. your Habitat co4ie sheet.
All values should match the riamrre
TOTAL Sq: Ft.
FINAL Sq. Ft.
TOTAL Feet
FIN
(Applled for.
(Anticipated final
(Applied for.
Disturbance
(AM
dish
DISTURB TYPE
Disturbance total
inclades any
disturbance.
Excludes any
total Includes.
Exc
Habitat Name
Choose One
anticipated
restoration
any anticipated
rest
tam
restoration or
and/or temp
restoration or
W_
Dredge ❑ Fill ❑ Both D Other
Dredge ❑
Fill ❑
Both. ❑
Other
Dredge [j
Fill []
: Both .❑
Other ❑
Dredge ❑
Fill ❑
Both ❑
Other ❑
Dredge ❑
Dredge ❑.
Fill ❑.
Fill ❑ :
Both ❑
Both ❑
Other ❑
Other ❑
Dredge ❑
Fill ❑
Both ❑-
Other El
J'

Pilirgs and More
910-327-6353 PA
AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit:
Mailing Address:
tla
Phone Number: 9Zr1— 7?6- $ 962
Email Address:
1 certify that I have authorized -Tve'' C/Yjj /o'� t
Aaeml i Contractor
to act on my behalf, far the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: /fin/ J,r✓Y f
at my property located at � 0- 4/�� '--f�/�1 ��C1wr'
G
in ©%Lf,4o'^l
County.
f furthennore certify that f am authorized to grant, and do in fact grant permission to
Division of Coastal Management sfaff, 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:
Signa
f
Print or Type Name
��CF1�ll
rme

Pbrgs and MOM
!)10-327-63S3 c 3
pROP�RT'[ TA =&A=ulr
hare+7� oerta fy that i ov*" Pr a karty 3dr"W t to 'r
(Nstw* a� Prcgsri Owiorl
fir'►' lAddt+", tat. filock. ROOd, .—_..
�9�ll�.a•1 . N r _
�— (CdyfTOW6 Wddor County)
Tim ttes "MCrtW3 to me, � s�vwn t�ldti+' thQ ci��reb��^sr►t ��d $ tha �vs
lo�1 havt! r00 pbOK-tion bC Mlis Gr'lf°
_ i Ivy�s +Objeri�ns �',17�s x*�tx+�
DE84CRJPTTON AMD-'OR DRAwHG dF PROPOSED DCALQPWNT
(htdhd4rN p opoalrg devwbprr+Rnt must NJ in cht9crlpb0n below or attsth a w tt dr^V$IV)
_ l XA
G,�.'t��
�iF n
. .I �U
T L l vt, 1�4 L
WAMEtStQBON
I UIX*Is1e d thm a pw, , t:tx,K "►'tuwN pt-'ng,16 owt rsr+v, b►eakwaW. bt O&K" $ fiR, ar Wcan
axat be sees hWk 8 m4 mum dcsUnae Of 15' horn mw area al npon= ecomm unk"3 wwveC oy
rive. 4" you wltrh to whew 0" You mLol t la{t1r1 +a iWVmg3rdit blonk rmgow )
1 CO msh In wd" Vm i } setwig mgtwwnenL
-- 1 do not wlst, tu w 66M tt►. 1 S' &#M*Ck Mgljim **-*
(prow"Ahxm Lion) tAdi� l I 1
P" Of T A ft* or Type Nam

Pilings and More 910-327-6353 p.3
,n a GE RIPARIAN PRO
t hereby certify that i awn property adjacent to _,i�i�i /JJ�irl� C•l1•��'�'�'� 's
(Nance of Property Owner)
property located at a4r �'•Md*&Lot, alock, Romid, ) �,� � N.C.
'!�'� �:oitJ9A in
�) (CitylT anchor County)
The pplicant has described to me, as shown below, the deveiopmerrt proposed at the above
location. '_�—�
I have no o*cUon to this proposal-
1 have objections to this proposal.
DESCRIPTION ANDIOR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
b
1 iZ
XJ
U � W1o11�R SECTl01�
1 understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse,, or groin
must be set back a minimum distance of 15' from my area of ripa i is access
blank o unless waived by
me. (If you wish to waive the setback, You must Initial the appropriate )
I do wish to waive the 16 setback requirement
47 L-�— 1 do not wish to waive the 16 setback requirement.
(PrWe atlon) (Adjacent Property Owner Information)
r " WY2V
Si
Signature*
o�0=1�en�o
print or Type Name
5o ��.- 4►1�(Mar ng Address 'A / /1
lilEi3f %riGB .IIPinL, {'Y, ,-%-71- i