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HOETIR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue James H. Gregson
Governor Director
AGENT AUTHORIZATION FORM
late: I1 f it
lame of Property Owner App ing for Permit -
failing Address-
� o FAX -2
101/7e� urS71, &) c ZSS 7
'hone Number: t/o � 2 cI — c-) �,& R
Dee Freeman
Secretary
certify that I have authorized (agent) ilc 130a %xtmse, to act on my
ehalf, for the purpose of applying for and obtaining all CAMA Permits necessary to install or
onstruct (activity) 41le i &//CAPJ a/Ld A
It (my property located at) //—Y S-/
'his certification is valid thru (date) �A/zZ
Iroperty Owner Signatures% Date

10/10/2011 07:04 9102969011 BF=EN CONSTRUCTION PAS
#ten af4'I v*A-
AI>«JACENT .RIPARJAN PROPERTY OWNER STATEMENT
(FOR A PIERffOORMPffXVGS/ OA-UU'. OOA7'HOUSp
I hereby certify that I own priaerty adjnent to Blily Breeden °3
(Name of Property Owner)
prop lbtsted at 328 Sanford St
(Lot, Block, Roads etc-)
on C11MCA , irx Hoiden Beach , N.C.
(Waterbody) (Town ai d/or County)
Applicant's phone #; (910) 295^62001-AUflittg Address: P.[7, Box 279
P,lnehurst, NC 28370
He has described to me,, as shown below, the development he is proposing at that location, and. I
have no objections to his proposal. l Unders€aztd that apier/moot;ng pilings I bontlift f boathouse
must be set back a minimum diswnco of fifteen feet (I5) from my area of riparian access unless
waived by me. (Uyou wish to waive 81blank
the setbaClt, y0a mast initial tits approprttxte
it ■ ��.
017. w
i Ampt wish to warv--
r�
1 I do wish to waive that setback requirement,
DMCWTION Ar�D&b Ari�.WIN13 of Ptto-POSM, DFVE �ojNT,
(To be filler! in hj! t}tdtvfduaJpropasing 4devej10jlnren0
Exis-tkv Lift T I I Dock
(Information for Property Owner .l ppiyibg
for Permit)
P5 6�x��
Mai ling Addrass
iArr'6� ��
�itylStatcl7 ip
qg
TrAirmhnnffUt A4 or
(Riparian Froperty Owner Information)
Si�tla;,o�
Print oz Type Name
%� ~ %3�X--0 � Y %

ADJACENT RIPARIAN PROPERTY OWNER STATEMt;M'
(FOR A PIER1t1'fOORING PILING&BOATLIFT 60,9'1'HOUSE)
l hereby certify that I own property adjacent to Biq Breeolen s
(Name of Property Owner)
property located at 128 Sanford St
(1.ot, Bloclt, Road, etc.)
on Canal _, to _ Holden Beach IN.
(Waterbody) (Town and/or County)
Applicant's phone tt: [phone] Mailing Addresc: P.D. Box 279
Pinehurst, NC 28370
1 to has described to tne, as shown below, the development he is proposing at that location, an+
have no objections to his proposal. I understand that a purr/rnooring pilings I boatlift / boathoz
must be set back a minimum distance of fifteen feet (l 5� from my area of riparian accoss unk
waived by me. (if you wish to-tvaive the sctbac c, you must initial the appropriate blank
i do nl2t wish to waive
wish to waive that setback requirement,
D SCRLPTION ANDIOR DRANVINC OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
(Information for Property Owner Applying
for Permit)
Mailing Addr=
r
city/state/zip
T plion V. u, er ,
f� .t. -7- It
(Riparian Property Owner Information
Sigt
Print or Type
'.
� �-6 3 t? 1
Telephonic Ni

PI L
Existing Dock
roposed Vinyl Wall F
128 Sanford St
roposed Pie
16, i
Cu

Division of Coastal Mgt. Habitat impact Computer Sheet
licant: W
IBrO Permit #: J�)
1
;vibe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
id in your Habitat code sheet.
TOTAL Sq. Ft.
FINAL Sq. Ft.
TOTAL Feet
FINAL Feet
(Applied for.
(Anticipated final
(Applied for.
(Anticipated final
itat Name
DISTURB TYPE
Disturbance total
includes any
disturbance.
Excludes any
Disturbance
total includes
disturbance.
Excludes any
Choose One
anticipated
restoration
any anticipated
restoration and/or
restoration or
and/or temp
restoration or
temp impact
temp'impacts)
impact amount)
temp impacts)
amount)
Dredge ❑ Fill ❑ Both ❑ Other
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Dredge ❑ Fill Both ❑ Other ❑
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Dredge ❑ Fill Both ❑ Other ❑
V" v
Dredge ❑ Fill ❑ Both ❑ Other
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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 ❑

JEFF N SIMMONS
DBA SIMMONS RENTAL 11
130 VIOLET ST SW
POBOX 7
SHALLOTTE, NC 28459
// 2n2- //
Date
3379
66-112/531
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