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PERMIT m Previous permit �'i!NERAL
w El Modification E Complete Reissue :]Partial Reissue Date previous permit issued
______
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Project Location: County Rules attached.
Address/daaik Street S/ Lot #(s)
M. M11
TI(s)
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NC Division of Coastal Mgt, Habitat impact Computer Sheet
4pplicant: (� �a Permit
Date: /
I2`z�,3
Describe below the HABITAT disturbances for the application. All values should match the name, and units of measuremen'
Found in your Habitat code sheet.
Habitat 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 fins
disturbance.
Excludes any
restoration and/
temp impact
amount)
Dredge ❑ Fill Both ❑ Other ❑
(0 U
lQ
Dredge ❑ Fill Both ❑ Other ❑
0
Dredge ❑ Fill ❑ Both ❑ Other
` �
v
Dredge ❑ Fill ❑ Both ❑ Other
1 To
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 0 Other ❑
Dredge ❑ Fill ❑ Both 0 Other ❑

kRDSON
'TRUCTION
5489
ZZ66-112/531
Date
'I
c Ale $
Dollars
r oomPANy
MOM
I
Iz- aIz4;v,1
OS 2-eS 2489 2 71,BOSL.139
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North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue Braxton C. Davis Dee f
Governor Director fi
AGENT AUTHORIZATION FORM
Date:
Name of Property Owner Applying for Permit: Name of Authorized Agent for this project:
-ran aj ��t1 � -,7S^n S
Owner's Mailing Address:
Phone Number0
Agent's Mailing Address.
Phone Number �i 0) L 4 2 U 3 3 4-
I certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
for and obtaining all LAMA Permits necessary to install or construct the following (activity):
For my property located at (F' 17
This certificat/ n is slid thri (date) T
T
PrJ6pdrty Owner Signature
J 1
Date

ADJACENT RIPARIANPROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGS/BOATLIFTIBOATHOUSE)
I hereby certify that I own property adjacent to -„\nFa s
(Name of ropert3Owner)
property located at X�f_,e_14r�r ti i n �1 i -
ll (Lot, Block, Road, ° ..)
on AX in MOW e P)e" � , N.C.
(Waterbody) (Town and/or County)
Applicant's phone 4 ` %- OW Mailing Address: �` 77r
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
do wish to waive that setback requirement.
c� --- ----------- —----- ---------------------------------------------- --------- ----- ------------- ------------
�-DIOR DRAWING OF PROPOSED DEVELOPMENT: DESCRIPTION A
(To be filled in by individual proposing development)
ec
(Information for Property Owner Applying
for Permit) r
Mailing Address
I c. a 2
City! tatel 4p
-------------------------
(Riparian Property
Informa
Pr
r- Name
Z_ /

ADJACENT RIPARIAN PROPERTY OWNER STATEM NT
(FORA PIEI?I IDORIIYG.PILIIY"GS/BOATLlTTIBOATSOUSE)
I hereby certify that I asvn property adjacent to'�- T"�
(lkame of ivrope(bwner)
property located at M� t ;) e (A) 14 iYA
T .(Lot, dock, (Road, e )--
on �.1 �• inL�t dQ !1PLi , N.C.
(Waterbody) (Town and/or County)
7ze F1'
Applicant's phoD`y` %-__ Mailing Address_ 1,Ua
C
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 I 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
';7t� I do wish to waive that setback requirement
DESCRIPTION A�•D/OR DRAWING OF PROPOSED DEVELOPhI:EN" T_
IYb be filled in by individual proposing development)
(Information for Property Owner Applying
for Permit)
'2 n A LeILQ
Mailing Ajddress V /! 1
S"P
City/Stage/ •p
(Riparian Property Owner Information)
f� J Signature
Print or Type Flare
s huinber Telephone NIumber

,c
ead Wall with
est Side
ad Wall
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