57490D - Floyd

C � ,
RCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management Dee Fr
Beverly Eaves Perdue James H. Gregson Se
Governor Director
AGENT AUTHORIZATION FORM
Date: C �, " � /
V( NameLoProper�tyOw�nerplying for Per it: ame of Authorized Agent for this project:
Owner's Mailing Address:
yin b r S
Phone Number (9/G4) 9- 7 40 --- 03
Agent's Mailing Address:
Phone Number (� --
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
;certific�atio, n is valid (date)
- - _ Date

M DELIVER
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(TOR A PIERIMOORING PILINGSBOATLIFTIBOATHOUSE)
I hereby certify that I own property adjacent to JIB C� m�' ��►� 1 _��_� s
(Name of Property Own rle )
property located at
(Lot,lock, Road, etc.)
- , in � C�'C�, N.C.
(�'Va erbody) (Town and/or County)
Applicant's phone #: 310'- 7L' 037 Mailing Address:
He has described to me, as shown below, the development he is proposing at that location, an , 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
I 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)
Mailing Ad re s
-----------------------------------------------------------
(Rip an Property O*n In orm o
M e li a ig1pre

AND DELIVER
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSBOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to LJJ
(Name of Property Owner)
�I1 V�J�.1 ly 1V �.nwu 4�
(Lot, B1oA4Road, etc.)
NL
C-
F1°7
CO, f n S� ,
on ✓► Q. , in N.C.
(Waterbody) (Town and/or County)
� Mailin Address:
Applicant's phone #: Mailing
Address:
has described to me, as shown below, the development he is proposing at that location,
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
_ I do wish to waive that setback requirement.
-----------------------------------------------------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
f
-------------------------------
(Information for Property Owner Applying (Riparian
for Permit) "---7
Mailing Address
------------------- ---- - - ---
erty Owe f mation)
M �, ' er"C ,_Signature
/ r�i/r>n ,6 Lira NCS—

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Division of Coastal Mgt. Habitat Impact Computer Sheet
icant: W.11 I Iawl " �VAa b Permit #:
l/-q c
tribe 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
temp impacts)
FINAL Feet
(Anticipated final
disturbance.
Excludes any
restoration and/or
temp impact
amount)
Dredge ❑ Fill Both ❑ Other ❑
50
'
Dredge ❑ Fill Both ❑ Other ❑
I cy
Dredge ❑ Fill ❑ Both ❑ Other
3Sa
c)
Dredge ❑ Fill ❑ Both ❑ Other
Z
`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 ❑
0,

GRICE CONSTRUCTION OF BRUNSWICK
COUNTY INC
6618 BEACH DR SW BS. 910-579-9095
OCEAN ISLE BEACH, NC 28469-4710
PAYTO THE
ORDER OF 1 1�� \� / \� \��
BRANCH BANKING AND TRUST COMPANY
A ' 1 1-800-BANK BBT BBT.com
.e
FOR 5 4-
n'0000 78 6 31i' I:0 5 3 LO 1 L 2 L1:000 5
DATE
1999 265 2911'
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