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NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Purdue, Governor James H. Gregson, Director Dee Freeman, Secretary
AGENT AUTHORIZATION FORM
Date / V$ ve/z
Name of Property Owner Applying for Permit:
Mailing Address:
I certify that I have authorized (agent) 5"4w C'A«y to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity) c193!:nftL_
at (my property located at) k-r ; od 4ye'�F'ti0
This certification is valid thru (date) 0 Vf Aa
.( //D i/ 1y
llatP

Dj ACE?IT RIPARIr131N PROPERTY' OWNER NOTIFICATIONIWANER FORM
he M-pose of this form is to provide proper nonce to You as an adjacent riparian property -owner to the individual or
individuals listed below. The CAMA General Permit application procedures require that applicants provide the Division of
Coastal Management confirmation that a written statement has been obtained siamed by the adjacent riparian property owne
indicating thar they have no objecr'on to the proposed work or that the adjacent riparian property owners have been notifiec
by corn ed mail of the proposed work. Often these forms are submitted to the adjacent riparian proper,, owners by a rnari;
cons -actor or other individuals acrine as an authorized a,ent on behalf of the applicant.
This form was sent to _you by the following individuai or company designated by the applicant as an
authorized age-+.--. _ ^
Authorize!^i . 3 Signature
Oc,
Date
Name of Individual a ppiyiug For Permit: 1z�-?//G✓
:address of Properrv:
(Lot or Street =, Street or Road)
(Cin and Counnj
,&.hereb` cerrif• that I own property adjacent to the above -referenced property. The individual applying for this pern
-` described to me a s shown on the attached drawing the development thev are proposing. A description or draw it
s.dimensions. should be provided with this letter.
I have no obiecdons to Phis proposai.
, n have objections to what is being proposed. please write the Division of Coastal Management,.I:
nil Drive Extension, Wilmington,C 28405 or call 91G}-79' 7215 within 10 days of receipt of this moth
sponse is considered the same as no objection if yol? have been notified by Certified �1aii.
WAIVER. SECTION;
I u,n4erstand that a pier. dock, mooring pilings, breaxwater. boat house or boat lift must be set back
Mi am distance of 15, from my area of riparian access - unless waived by me. (If you wish to waive t
setback, .you must initial the appropriate blank below.)
I do wish to waive the i T setback requirement.
I do not wish to waive I5' setback requirement.
MRDare NCDE

-, D=;CTNIT R,PARIAN P;�Q°ERT" 0AIN=ER NOTTICATIONMANEI? FORM
The purpose of this fortri is to provide proper nonce to you as an adjacent riparian property owner to the individual or
individuals listed bellow. The CAMA General Permit application procedures require that applicants provide the Division o
Coastal V(anaeemenr confirmation that a written statement has been obtained sip—ned by the adjacent riparian property owne
indicatine that whey have no objection to the proposed work or Char the adjacent riparian property owners have been notinec
by ce, rifted mail of die proposed work. Often these forms are submitted to the adjacent riparian property owners by a marii
contractor or other individuals acting as an authorized agent on behalf of the applicant.
This form was sent to you by the fallowing individual or company designated by the applicant as an
authorized agent:_ ! - -
authorze : s Signatufe
Dare
Name of individual .^.ppivitlG For Permit:
Address of Prope.'ty: C;t X/V/t AV,6j.-
(Lot or Street =, Streei or S.oaQ)
c A4*i- /1/( 09
(,Cite and Counrv)
:bN certify that I own proper ry adjacent io he above -referenced property. The individual applying for this per
.escribed to me as shown on the attached drawing the deveiopme nr they are proposing. A descriprion or drawir
dimensions. should be provided with this letter.
i have no objections to this proposal.
Hsu have objections to what is being proposed. please write the Division of Coastal Management, 1.
Ai; 1ai Drive Extension. Wilminb on. t C 28 ©-9 or call 910-7,96- 215 within 10 days of receipt of this noria
resiv snse is considered the same as no objection if you have been notilied by Certified Mail.
WAIVER. SECTION
I u-r€ers-tand that a pier, dock, mooring pilings, breakwater, boat house or boat lift must be set back-
M: turn distance of 15' 'roan any area of riparian access - unless waived by tree.
sethopk,. you must initial the appropriate blank below.)
I do wish to ;,aloe the 15' setback requirement.
I do not wish to waive #z�e '_ 5' setback requirement.
NCD,E--NR
RESatraret
Dare
-T�_ h0 . /1/ "A
(If you wish to waive t

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C Division of Coastal filgit, Habitat Impact Computer Sheet
'plicant: • K[�v,"A ))610��Yyu('L
Permit #: q19 5tol'
scribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
ind in your Habitat code sheet.
bitat 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)
AL Feet
icipated final
rbance.
FExcludes any
oration and/o
p impact
amount
50
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PILINGS AND MORE
JOHN CASSIDY 6015
PH: [phone]
169 LAKE HAVEN DRIVE L/ � r �/ 66-30/531
SNEADS FERRY, NC 28460 f 457
Date
PoyrdOtero Nc12-
1 $ /000' v U
Dollars
Yc4.
Fast Citizens rW I (o D
Bank P 5 Wp 11-D
firstcitizens.com
1:0531003001:00457 13 27011411`v66015