56650D - Allen

910 329 9151
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North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Bever y Eaves Perdue James H. Gregson
Governor Director
AGENT AUTHORIZATION FORM
Dafe� 141 1
',ame 0` Property Owner .reu!ying for Penn:t.
M 1}vj 5 AtLLF-N
owners Malting address:
Po soli- 3 -70
Fo k n. 0 A -KS Jy L
0. 7 5 PL Lf
Phone Number ( 415 9 t 3- a 1 y 6
.%F /1:
P.bl
Dee Freeman
Secretary
Name of Authorized Agent for this protect:
T�CA - _161 Y �-,'
Agent's Mailing Address:
119D S. Pa,K.c.✓
Phone Number IrJI 3in-0:722-
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):
.. C,A
(my property located) at �_ c
--) TH
This certification is valid thru (date;
f
Property Cwner Signature Date

"211 06 48a Adler, 6 S6nsCaL.n5l Shop
slaae�saes
09,4 V '�
DWMON OF COASTAL XkV. AG&MEN'T
AWACENT WARiAN PROPERTY OWNER STATE. T
I herrby Cen&, that I Cw>r ptvperty At> :o opn R- o M Ar V 1 S g L�L E n ,s
(Nmne of Proeerty Owner)
Pcope-ty 1ocsied at -7 ,o IX -7
(W. Block Road, etc )
on z AIN 4 IL in OIv S C G k- , N.C.
(WuwbodY) (Town sad/or County)
AppliMt's Phan ic- q f 1 q t 3 2) [ MeAz4 Addy= Po d4 vx 3 7
�o� a O nRcS NC 1 Z,C 1y_
Hd9!+a has describe:.' m the as shown balo�v t>as deve4ppmcs: 2teJ3be is prc�caina at dtrt IotatiOts,
and I have no objacdoas to the proposal.
?f! 57 Cir-T
DESCRIPTION ANVOR, DRAVvMgG OF PROPOSED DEVELOnMN-T:
anWidaidproposing ArveloPowitt mAWJtu In dewt*dox below or so=h a sets drawbW
11 you have oejaeem to VW to tf des propoM4 you Mast netily the Divaua of CaasW massieaswat (DM is w:t irg
waken 10 days of recalpt of tots aedtce. Cvrtapoodence **vA be masind to :n Carttisal Drew Zit. wftfttcoa, r c
DCM rtptcmmdm can aim M costsmd at (Ml0) 7tK-723S.
*to sonata is sostSQsrae tea ysstu a�obltalae �f �rsu stew Mm t
(PropertyOwaes Zatorae
Stgtiatutt:
Prim or Type Vme
YU
Mailing Add=
City / State / Zip V_q
.elepbot+eN�aber 91 d ^ 3 °_ ,
(Riparian Property Ow= Informadat)
Sjra
J
Print o::�pe Name
Mailing Address
c�/Stel�
T
Tslaphoe* Number
Dates 3 i.i -//

?2 11 09.12a Southeast Acute Services
/0424342by P.
818-9833Q$5
221108:04a Allen& Sons Cabinet Shop -- ---
R IM MIL- - RETURN- RECEIPT R£O. -JoT
DIVISION OF COASTAL MANACEMEN T
ADJACENT RIPARIAN PROP£R2Y OWNER STAT£M£NT
pI
N_oz
I hereby certify that I ovrt; property adjacent to D ON A v l S /} LL F �Y
(Name of Prop" Owner)
Property located at % O d1 i S Q f- � i
(Lot, Block, Road, etc.)
on _ _ LAN t_ n_ o ly S L o t✓ , N , C.
(Warer-body) (Town. and/or County)
Applicant's phono #: 9 t 1- `3 - ? ! Mailing Address: Po 6 Cx 3 O
F o 2 0 H- K S !V c Ii- 7 S 0- y
fie/Shc has described to me as 1-hown below the devslopmient he/she is proposing at that location,
and i have no objections to the propoaal.
DESCRJPTION AND/OR DRAWLYG OF PROPOSED DEVVELOP1viENT:
( ndd Nfffff olgijU*rJQQ[gr#J' i�flf t'u rinurstirn i.t� n t t
No reaeonm Is ZM lder4d the tams M by vbly t n It von hya gotiMd b!r !CcrAtd W
(prop" Owner Info �M* (Riparian Property Owner lafwmarloa)
5i a Sigttatwe
Print cr Type Nuns Prim or Type Marne
Mailing Address
qZ 4 X H fl W 1. A/ Z i 7 3
City / State / Zip
Talephone i`umber JC) `f -- S 33 `-17.3f
ate 3 - 22- L /
Mailing A&nw
City / State / Zo
Telepbone Number
Bate
127 Cardinal Drive Fxt., WhmirVW. NoMh Carolina 264W3U5
Phone, 910-716-72151FAX [phone]kimernet www.ncco=Wmanegemevri.net
An E4U4 0MoMW Y t AM"M1 i S A6M EVky& - M tte VOW r 17% PON 0r&KW P3M

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Division of Coastal N19t, Habitat Impact Computer Sheet
av`S b%&M)licant:M JS N 1&4A�, Permit #.
e.3/3a/\�
cribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
id in your Habitat code sheet.
itat 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 ❑
2,UGj
Dredge ❑ Fill ❑ Both ❑ Other ❑
Z
l Z
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 ❑

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