57453D - Clapp

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date i - is' 13
Name of Property Owner Applying for Permit:
r-
�Jol1�
Mailing Address:
AIC
I certify that I have authorized (agent) l��na�r► �i�c 4r� r` to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity) &) l 14 11 �c�-o�
at (my property located at) ✓V-VV-
This certification is valid thru (date) 1Z -31— / 3
3-1-13
Owner Signature
Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSBOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to J0 n �LetAQ is
(Name of Property Owner)
property located at J Z 1 39 r'a q ya-
(Lot, Block, Road, etc.)
on 6ei'ia( ,in 0 54,l &A64 / e,,,LeLr N.C.
(Waterbody) (Town and/or County)
Applicant's phone #: q10367 2-1SR Mailing Address: "/ Z 4L,",14e Cf
28HH3
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 fifteen feet (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 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)
/
�I -
-----1�--------------------- C-1---------------- 1 �------- t ec,) t--5------------------
(Information for Property Owner Applying (Riparian Property Owner Information)
for ermit)
>
Mailing Address Signature

scribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
end in your Habitat code sheet.
TOTAL Sq. Ft.
FINAL Sq. Ft.
TOTAL Feet
FINAL Feet
(Applied for.
(Anticipated renal
(Applied for.
(Anticipated final
�itat Name DISTURB TYPE Disturbance total
disturbance_
Disturbance
disturbance.
Choose One includes any
Excludes any
total includes
Excludes any
anticipated
restoration
any anticipated
restoration and/or
I
restoration or
and/or temp
restoration or
temp impact
temp impacts) -
impact amount)_ I
temp impacts)
amount)
Dredge ❑ Fill ❑ Both ❑ Otheyh I 2W4->
Dredge ❑ Fill ❑ Both ❑ Other ❑
Both
■ Complete items 1, 2, and 3. Also complete
item 4 if Restricted Delivery is desired.
■ 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.
I. Article Addressed to:
sZ-5- le-Z Ab-i �W
�)&14-,NL z75g/
X - ❑Agent
❑ Addressee
Race. Pre ame) C. Date ol Delivery
Z 13 fl
D. Is delivery address different from item 1? ❑ Yes
If YES, enter delivery address below: ❑ No
3. Service Type
Certified Mail ❑ Express Mail
❑ Registered ❑ Return Receipt for Merchandise
Insured Mail ❑ C.O.D.
4. Restricted Delivery? (Extra Fee) -
2. Article Number ❑ Yes
(transfer from service iabeq 7 012 1640 0000 1120 9105
PS Form 3611, February 2004 Domestic Return Receipt
Dredge Li 1-II1 Li tso[n U vuw, L-, , 102595-02-M-1540
Dredge ❑ Fill ❑ Both ❑ Other ❑

Bank of America
ACH R/T 053000196
,LLIED MARINE CONTRACTORS, LLC 08-03
910-367-2159
92 HAROLD CT.
HAMPSTEAD, NC 28443
3 1- t 3
$ at)
5644
66-19/530 NC
58754
ryr/�'� DOLLARS I`i
=�A1,
�j ci r,l
Y)y S p _..._._.... AUTHORIZED SIGNATURE__._.._._W._
V