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�plicant: � r 12 ov-1
to: ///---
LI
Permit #:
scribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
nd in your Habitat code sheet.
iitat Name DISTURB TYPE
Choose One
TOTAL Sq. Ft.
(Applied for.
Disturbance total
includes any
anticipated
restoration or
temp impictsll
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 final
disturbance.
Excludes any
restoration and/or
temp impact
amount
Dredge ❑ Fill ❑ Both ❑ Othe
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 ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

ANTINORI CONSTRUCTION, INC.
252 ENNETT LANE
SNEADS FERRY, NC 28460
TO THE R
DER OF��-
Bank of America'
ACH R/T 053000196
66-19-530
2665 1
m
- � o
m
$
o'EleDOLLARS
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m
8
AUTHORIZED SIGNATURE

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner-. kos L 0- L
Address of Property: —1 oq D I S�' S �V �
Lot or Street #, Street or Road, City & County)
�f� vl�lyw-e_O
Applicant phone#: 500• 3a--I• 39_1:�_
Mailing Address: 2-�-- Lh yje �-
SneMc K v ' i�C 2�
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.nccoastalmangement.net/contact 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, or lift 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 Info ation)
�� D
r
44- — -
iv,
Sigriature
k, y.. l :_7a fZ L-
Print or Type Name
(Riparian Property Owner Information)
Sign ttuereAzi,Lek& y t_
L/AJaA MCRR, 7T --
Print or Type Name
AA -;I;-- AAAoo
q & &o _1fw'
Mailina Address

CERTIFIED MAIL - RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner: I< �_,1, E-U-e- L
Address of Property: oq D -111- S�, Suv p L( / D n'sI O V\
Lot or Street #, Street or Road, City & County)
VybYuk.1
Applicant phone#: Cj 10. 3 ��• �H�� Mailing Address:�{rl �e �f W1
S�eacas t ✓r� i�1z 2g
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.nccoastaimangement.net/contact 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, or lift 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 Information)
Signature
k.v- I �i1►2 �
Print or Type Name
-.A
(Rip ian Property Owner Information)
Signature
Print or Type Name
-*76q q /10 t'
Mailing Address
Mailing Address ,

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date I Z. 1 "2 6) 13
Name of Property Owner Applying for Permit:
Mailing Address:
� 5 31 W(A IQ F-AIIr, rz
Waft fby (,s-r NrC
I certify that I have authorized (agent) Anbym,( CA)Y1Si, -fLU J1 bA / to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity)
at (my property located at) 1 0 q a � � S-
This certification is valid thru (date) 'bt,,(— Q a- 0l --e�
I2Z
� JJl
Property Owner SignatGre 01 'N Date

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