69332D - Wall

Ais-
No
:;•►r

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: H a � And Gall WQI I
Mailing Address: k \ S SW -i +h 5-1ve-e-+
(901L lsla"J , Nc 2 Sys
Phone Number: f7 (ol Z 005C1
Email Address: Kwat I Oec. rv. ta&.\-
I certify that I have authorized IV\LIAVA�s ( Ar ka-CjwKz-s , `e- 5G YYIPW�
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
at my property located at ' 15 SW -141A S+-
inLYtAA-'W Ck County.
I furthermore certify that I 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:
-Wtj0),
Signature
�a I Oat �
Print or Type Name
Title

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I
I hereby certify that I own property adjacent to t�l a [ GnA 60-1 t IN a. I I 's
Name of Property Owner)
property located at � 1 s SVJ "1'n" 54. 1 L -11 , $ - 21 , S - 15
on (Address, Lot, Block, Road, a c.)
in gale- 151N.C.
(Waterbody) (City/Town and/or County)
The applic t has described to me, as shown below, the development proposed at the above locati,
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.
(�r party Owner Information)
urg-&jal
P 'nt or Tye Name
(Adjacent Property Owner Information)
Signatu'L C '^
Print or Type Name 7
q(aaI � dalC��- Qr

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to a WA- s
(Name of Property Owner)
property located at 115 Isw .St, L - ( - 21-1
(��� L / (Address, Lot , etc.)
lock, Road
on 1 T�"1 in _ L IS1 N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above locatii
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)
9,E'�(IAt E cio k+ OF 3uL-Y. rkf; p
SEE A T iACKE6
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. 4A
I do not wish to waive the 15' setback requirement.
(Fro erty Owner I formation)
� all
Slg�Qre' , 0 Q I '
Prjn1 cy Types o 71-k-
(Adjacent Property Owner Information)
Si nature
CV1,9v es r 'Qaw-t'& PGwr[,l 1
Print or Type Name

d � �j �r � � i' F T ���::.; .� � �(,�1^'1►�1Cr '�?� I-�N 10Yys i
1/fr 1 J-,w*% �/ n!d TTw1r_ r\tv-
�Vvvv.--
N C 2Rwi P --
6
_
�lohT�
v
`)- LOT
o O
�xi