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C Division of Coastal Mgt. Habitat Impact Computer Sheet
)plicant:
&Aj-ka kA Permit #: 5-tqm�
ate: 6 /-b 1 13 1
)scribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
and in your Habitat code sheet.
ibitat 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 final
disturbance.
Excludes any
restoration and/or
temp impact
amount)
Dredge ❑ Fill ❑ Both ❑ Other
I b
O
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 ❑

3E CONSTRUCTION OF BRUNSWICK 8985
COUNTY INC
6618 BEACH DR SW BS. 910-579-9095 66-112/531
OCEAN ISLE BEACH, NC 28469-4710
DATE
l DOLLARS "
BRANCH BANKING AND TRUST COMPANY
� 1-800-13ANK BBT BBT.com
85n■ i:053 LO L L 2 0:0005 L999 265 29n'

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WCDENR Resources
North Carolina Department of Environment and Natural
Division of Coastal Management Dee Fre
Beverly Eaves Perdue James H. Gregson Sec
Director
Governor
AGENT At FORM
Date:
Name of Property Owner Applying for Permit: Name of Authorized Agent forthis project:
Owner's Mailing Address:
-T— G
Phone Number a)Q 7,5 cZ S
Agent's Mailing Address: S` \
Z`�tlo�a
Phone Number y�
I certify that l have authorized the agent listed above to act on my behalf, for the purpose of applying
f 11 win (activity)
for and obtaining all CAMA Permits necessary to install or construct the o o g
(my property located) at
Thi ce ification is valid thru (date)

HAND DELIVER
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSIBOATLIFTIBOATHOUSE)
I hereby certify that I own property adjacent to �� I�rtt s
(Name of Property Owner)
property located at
(Lot, Block, Road, etc.)
on in n C` n �, ,n �+� 10 �ecn- , N.C-
(Waterbody) (Town and/or County)
Applicant's phone 9:212 Mailing Address: a r �---
T ��4
He has described to me, as shown below, the development he is proposing at that location, and, I
have no objections to his proposal. I understand that a pier/mooring pilings / boatlift / boathouse
must be set back a minimum distance of i f<cen ftict (15') frorr. 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 not wish to waive
I do wish to waive that setback requirement.
-------------- ----------- ---------------- --------------------------------------- ----------------------------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
(Information for Property Owner Applying
for Permit)
Iailing Address
'moo �86'z% 6.Z
�L Tsl& �eac !� C>
(Riparian perry Owner Information)
Signature
&eqd
l,___ _

HAND DELIVER
ADIACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIERIMOORING PILINGSBOATLIFTBOATHOUSE)
f
I hereby certify that I own property adjacent to s rye tt -� s
(Name of Property Owner)
property located at
(Lot, Block, Road, etc.)
on C & , in C or, ri -
(Waterbody) (Town and/or County)
Applicant's phone #5s Mailing Address:
He has described to me, as shown below, the development he is proposing at that location, and, I
have no objections to his proposal. I understand that a pier/mooring pilings / boatlift / boathouse
must be set back a minimum distance of fit crzn fccA (I S') 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 not wish to waive
I do wish to waive that setback requirement.
--------------------------------------------------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMI~,NT:
(To be filled in by individual proposing development)
(Information for Property Owner Applying
for Permit)
n�Pe-14a�
M�11 gs��b (�
14 c
49�
(Riparis Property wner Information)
.. c
(� Signature