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HomeMy WebLinkAbout57406D - Bent=I P El ffil 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' TA XA©I7 d3 'A. N!, t. 2013 Goog le f:? ROTA,17111*1 Goosle r 41- 4 �= a i /I Ax Wit ---, ..� 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