57600D - Purcell

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WMENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
everly Eaves Perdue James H. Gregson
Director
,overnor
Dee Freeman
Secretary
AGENT AUTHORIZATION FORM
Dater
0—
Name of Authorized Agent for this project:
acme of Property owner Applying for Permit:
rync Ifi
owner's Mailing Address:
d
CIOAU) Al G � '3
'hone Number t 14? -5-9 20 ME
-
Agent's Mailing Address:
Phone Number3(e1 Ise Z©1
i certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
for and obtaining all CAMA Permits necessary to install or construct the following (activity):
(my property located) at
This certification is valid thru (date)
Property Owner Signature
b 30 %
Date

4,k
��L

HAND DELIVER
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(TOR A PIERIMOORING PILINGSBOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to i,J ' �J �. is
(Name of Property Owner)
property located at .3 21 q4horu- —516
(Lot, Block, Road, etch.)" %
on �I � I , in OCe� IS e_ &AC L N.C.
(Waterb�o%dy) 2 Q �J (Town and/or County)
Applicant's phone #: /10,/0u ~6 /©flailing Address: / 7
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
60'' II 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)
/07 f Ad
Mailing Address
sRU39-
--------------------------------------------------------
(Riparian Property Ow ffnformtion)
i
Signature
IJ .0 IS.Z- o/

HAND DELIVER
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSIBOATLXFT/BOATHOUSE)
I hereby certify that I own property adjacent to Td 0',.1 z A's
(Name of Property Owner)
property located at 13 ),
(Lot, Block, Road, etc.)
on �I 14 I , in ©ce, Z/ N.C.
(Waterboody) D (Town and/or County)
phone #: /1030o —. 19A ailing Address:___��"" �
�/tel kA) .1 1U(J Z
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 (I T) 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 l /
do wish to waive that setback requirement. vP
-------------------------------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
--------------------------------------------------------------------------------------------------------------
(Information for Property Owner Applying (Riparian Property Owner Information)
for Permit)
lo 7 A5,(- Rd,
Mailing Address Signature
144)
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Division of Coastal Mgt. Habitat Impact Computer Sheet
licant: A L PmQL( Permit #: S 6(� D
;vibe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
d in your Habitat code sheet.
tat 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
tem impacts)
FINAL Feet
(Anticipated final
disturbance.
Excludes any
restoration and/or
temp impact
amount
Dredge ❑ Fill ❑ Both ❑ Other
I
a-
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 ❑

WILLIAM DEREK EDWARDS 05/10
33 RAEFORD ST.
OCEAN ISLE BEACH, NC 28469
PAYTHE / 6e 94e �
ORDERER OF /�/ J
RBC Bank'
RaiBak n
: �� S
MEMO O /
1:0531008501: LO3301257 Lus
66-85/531
DATE / , &- / Z
1084
DOLLARS 8 o�""..--