63216D - Middle

SRUCE MAREK, P. E.
MAREK YACHT DESIGN CONSULTANTS
5489 EASTWIND RD.
WILMINGTON, NC 28403
�yE�D the
I III YG�QY D�
-
1336
m e
66-211530 10402
2075080394099
-- e
Wells Fargo Bank, N.A. °°�
e North Carolina
wellsfargo.com

Division of Coastal Mgt. Habitat impact Computer Sheet
licant: 11���-� Permit #: V3 V' ,
Y40
cribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
id in your Habitat code sheet.
iitat 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.
Excludes 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/c
temp impact
amount)
Dredge ❑ FillCY Both ❑ Other ❑
Dredge ❑ Fill [,Both ❑ Other ❑
f�
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 ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner:
Address of Property:
(Lot or Street #, Street or Road, City & County)
9
Agent's Name #: & ye er /-/,m � , Mailing Address:
Agent's phone #: - / / 7 Yj 2 J1_
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. Contact information for DCM offices is
available at www.nccoastalmana_gement.nebcontact dcm.htm or by calling 1-888-4RCOAST. 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 Inf rmation)
.&"
Signature
Print or Type Name
/ �w T�Wez J a� 4-
(Adjacent Pfoperty Owner Information)
// f f
134giTture
Print or Type Name
AA4,0 �6ra A

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date r6.
Name of Property Owner Applying for Permit:
+Dt7LE t ti►D I�1fiR«/.� , f Nc. GNhR S �OU.AJ r p26s
Mailing Address:
1-711c3frwE,- 60x - P 3L2-75--
i¢Nr 6 E tw- rL 3 3 7.57 C'f-! ,r R. c.-0 Tir /11W :$-Z,3 Z--
I certify that I have authorized (agent) 162 o e,` f7^AKC-E K P. ice, to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity) &V!2j (R O R- ,eE& A I-E
at (my property located at) /-i r-tib c 4' 1 s;-+A;-b 1'11A-1c r rv.f
CoN CAP6 CROEK
This certification is valid thru (date)
Property Owner Signatu
Date

i Complete items 1, 2, and 3. Also complete
Item 4 if Restricted Delivery is desired.
I Print your name and address on the reverse
so that we can return the card to you.
i Attach this Gard to the back of the mailpiece,
or on the front if space permits.
I. Article Addressed to:
r 5V-S00"XA)ar
H-J: CC'y1S-e-rV0-y1C-'-y
A, SJ)g
;a ure
gent
ZVIL144 Ag0 Addressee
& Jcej,,if by (Pnnted Name) I GA`lale 0111?elivery
D. Is delivery address different from Rem 1? U W1
If YES, enter delivery address below: 0 No
2,5
PC 60 '3 3' Service T 0 Certified Mail vss Mail
EJ Registened 0 KRum'Fl�pt for Mf�hrclise
El insured Mail 0 C.O.
4eoA
4. Restricted Delivery? (Extra Fee) Yes
2, Article Number 7013 3020 0001 6374 1299
(Transfer from service lab&)
PS Form 3811, February 2004 Domestic Return Receipt 102535-02-M-1540
DGM WILMINGTON, NC