69041D - Svingos

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NC Division of Coastal Mgt. Habitat Impact Com
Applicant: A&6kV\( Sm,,,Wo�
Date: j/ lf
7�Q
Describ©below the ABITATdisturbances 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
Dredge ❑ Fill ❑ Both ❑ Other 4
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I a g
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'20-A14 S-- Z)'O
Mailing Address: 3 y L
Phone Number:
Email Address:
I certify that I have authorized
30q- & 3,P-05-71
y tacq com or Gfd-�-►4 de
Agent ! Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: (jug yr $ �`
at my property located at 3& Mwoe Sk6-94 O«az Isle 8eael -'L
in /34tt," u-�i uK County.
t 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:
Si9dature d
m al l S V, 'n_.q 0 S
Print or Type Name
() U-) E r'
Title

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to A r SVi s Is
// (Name of Prope wner)
property located at .�(� fy%orrrcc� S'�V'Pe�
C a-1 qJ (Address, Lot, Block, Roads ein Ts
tc
(Waterbody) N.C.
(City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above locatio
1 have no objection to this proposal.
I have objections to this proposal.
v' DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
_ (Individual proposing development must fill in descripdon below or attach a site drawing)
� F
�.✓r.N q olech. r.�tt
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set bad
minimum distance of 15' from my area of riparian access unless waived by me. (If you wish to wai,
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.
p-roperty Owner Information)
Signature U—
Print or Type ame
(Adjacent Property Owner Information)
Sig
lure
a,
Print or Typ Name

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to _ Kary Sv-[►�4 a5 is
property located at 36 Moore o S-�ree� (Name of Property Owner)
C p (Address, Lot, Block, Road, etc.)
on c n�C in Or P .z1 - 4 1e 6fafA. N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above locatio
in 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)
7...
V)
W,e -Ae- /tYAU
{ WAIVER SECTION
' I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set bah
minimum distance of 15' from my area of riparian access unless waived by me. (If you wish to wai
the setback, you must initial the appropriate blank below.)
ryI S%/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)
"
Signatur r J y Signa ,ure
Print or Typ�e�J Print or/Type Name
J t

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