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NC Division of Coastal Management
Cashier's Official Receipt 0327
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Date: 20 L {
Received Fr
Permit No.:
Applicant's
Project Add
Please retain receipt for your records as proof of payment for permit issued.
Signature of Agent or Applicant: ' ,F
9 9 PP Date: � s
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14 C D9visio of Coastal Mgt. Habitat Impact computer Sheet
Applicant:
V
Date:
Describe below the HABITAT disturbances for the application. All values should match the name, and units of measuremeni
found in your Habitat code sheet.
Habitat Name
DISTURB TYPE
Choose One
TOTAL Sq. Ft.
(Applied for.
Disturbance total
includes any
anticipated
restoration or
temp impacts)
FINAL Sq. Ft.
(Anticipated final
disturbance.
Exdudes any
restoration
and/or temp
impact amount
TOTAL Feet
(Applied for.
Disturbance
total includes
any anticipated .
restoration or
temp impacts)
FINAL Feet
(Anticipated fina
disturbance.
Excludes any
restoration and/(
temp impact
amount)
Dredge ❑ Fill ❑ Both ❑ OA
Dredge [I Fill ❑ Both ❑ 0
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 ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other .❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both [I Other ❑
Dredge ❑ Fill ❑ Both 0 Other ❑

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NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue, Goy James H. Gregson, Director Dee Freeman, Secretary
Date o13(is
Name of Property Owner Applying for Permit:
p
Mailing Address:
i10 JV\ �r`Oy\ LrPtV— 'i •°
(i'�':M S t , Z. 43 -j H 7)
I certify that I have authorized (agent) kk-k i�v��ClWiJ� � tl�e� ?flan 1C�ro act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity) t I? i ' 6O G
at (my property located at) 10 !kqc z>111 r e t t�- - s v
This certification is valid thru (date) / Z — 3 % — f S-
1
Property Owner Signature
Date
400 Commerce Avenue, Morehead City, North Carolina 28557
Phone: [phone] \ FAX: [phone] \ Internet www.nccoastalmanagement.net
An Equal Opportunely 1 Affematm Action Employer — 50% Recycled l 10% Post Cws mer Paper

■ 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.
1. Article Addressed to:
71/3 .gam Cre-ek- i)r.
S i ^/6- 2��IN3
❑ Agent
i Addressee
by (Pnnled Name) C. Date of Delivery
D. Is delivery address different from item 1? ❑ Yes
If YES, enter delivery address below: ❑ No
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3. Service Type
0 Adult Signature
❑ Priority Mail Express
O Registered MaiIT'^
❑ Adult Signature Restricted Delivery
❑ Certified Mail@
❑ Registered Mail Restricted
Delivery
9590 9403 0112 5077 7955 46
❑ Certified Mail Restricted Delivery
O Return Receipt for
❑ Collect on Delivery
Merchandise
2. Article Number (Transfer from service label)
❑ Collect on Delivery Restricted Delivery
0 Signature Confirmation-
7 015 0 6 4 D 0 0 0 0 2878
0 Insured Mail
752 8^ ­ 0) it Restricted Delivery
❑ Signature Confirmation
Restricted Delivery
PS Form 3811, April 2015 PSN 75 - -
Domestic Return Receipt
■ 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.
1. Article Addressed to:
If YES, enter delivery address below:
Z `'�Y 3
3, Service Type
❑Priority Mail Express®
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III
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III
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❑ Adult Signature
❑ Adult Signature Restricted Delivery
❑ Registered MailT^
El Registered Mail Restricted
9590 9403 0112 5077 7955 39
ertified WHO
Certified Mail Restricted Delivery
Delivery
❑ Return Receipt for
❑ Collect on Delivery
Merchandise
ni,—har'Transfer from service label)
13 Collect on Delivery Restricted Delivery
0 Signature Confirmation-
7 015 0640 0000 2 8 7 8 7 511
n'"" ""� Mail
Oail Restricted Delivery
❑ Signature Confirmation
Restricted Delivery
PS Form 3811, April 2015 PSN 7530-02-000-9053
Domestic Return Receipt

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