57450D - Middle

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
McCrory Braxton C. Davis John E. Skvarla, III
ovemor Director Secretary
AGENT AUTHORIZATION FORM
Date: (�
ne of P perty Owner Applying for Permit: Name of Authorized
Agent for this project:
ier's Mailing Address:
o - 07 4
P�a�43
Agent's Mailing Address:
one Number (*0 )2-p—d 171 Phone Number T42 ) SL? K cf:Z :7
rtify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
and obtaining all CAMA Permits necessary to install or construct the following (activity):
my property located at 5 ( O —
certification is valid thru (date)
Property Owner Signature Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to i�') t /�=�:, tLlI i �_ is
(Na a of Property Owner)
property located at c� I„ ;,,� ��cr� -1:
(Lot, Block, Road, et )
on Ul/�v' , in 3 ActC/ , N.C.
(Waterbody) (Town and/or County)
Applicant's phone #: Ito - 5-3 &=-- J ? "3 '7 Mailing Address: 6%Z S' a
He has described to me, as shown below, the development he is proposing at that location, and, I have
no objections to his proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
(Information for Property Owner/Applicant
Applying for permit)
2Joc�� �Gt�-�D � �OISTi�In Wc� �e�d',✓
Mailing Address
%A0, ski
City/State/Zip
(Riparian Property Owner Information)
a
Signature Jt=g- f 1L ^"_
7 i-VX�-I V FYI
Print 6r Type Name
tO-S3if i 7 3 7
ehnnP Mnmhar
508 E. Windward Landing Pace
Hampstead, NC 28443
r�/�o��in /► A!1`lrnon (~it.r �raru i...

14e Cc S
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to
)roperty located at
/ yr—I
j "A -. of
C_Cst,,,t�� .t �
(-( o / }
is
r(y Owner)
f'C'4 /&i-
(Lot, Block, Road, eta,)
rn T G GN W , in N.C.
(Waterbody) {Town and/or Conn)
kpplicant's phone #: [phone] Mailing Address: 5 hc--}I'ef �cf
�1 r 1 rvt«► �U • c_ 2- S-L(c)cl
3e has described to me, as shown below, the development he is proposing at that location, and, I have
io objections to his proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
Cnformation for Property Owner/Applicant (Riparian Property Owner Information)
A pplyin- for permit)
3"1 44' QeJ zoz-
lailingg Addre s Siekture
0V 2 kV Y 3
ity/Stat /Zip Print or Type Name / /
[ --- Xr,.... u— A�ra;t;.,., �-

0
17
%S� 1
/I l�
3
r�
T"
m
14c-7
v
i
O
c

n Ae ult ►I�
IDS f 544 �e^ Co in v—YA- /
pvio-✓
01& % �� 00"YA t

Loos- All,
)licant: �l/ �i
z ` ?'O Permit#: e: ^
l,3
cribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
id in your Habitat code sheet.
tat Name DISTURB TYPE
Choose One
TOTAL Sq. Ft.
(Applied for.
Disturbance total
includes any
anticipated
restoration or
temp impaacts)
FINAL Sq. Ft. TOTAL Feet
(Anticipated final (Applied for.
disturbance. Disturbance
Excludes any total includes
restoration any anticipated
and/or temp restoration or
impact amount) temp impacts)
FINAL Feet
(Anticipated final
disturbance.
Excludes any
restoration and/or
temp impact
amount)
� Dredge ❑ Fill ❑ Both ❑ Other
/ �[J �
OS
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 ❑

4--
ti
ASTAL CONSTRUCTION CO. 8522
B PARK AVE.
3TON, NC 28405 67-7194-2532
0) 538-9737
n DATE 2 12
28?�.
i�rEk DOLLARS
d.
, C P S-7` 1so p 01- A