57512D - Hodges

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ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSBOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to H��l' V\dx&t=-S is
(Name of Property Owner)
property located at Li 0 IS y"'rys 5
(Lot, Block, Road, etc.)
on C2�14AL Ir s , in 6z;Tt' Lx i N.C.
(Waterbody) (Town and/or County)
Applicant's phone #: c�10--3--AA- 1'SCk) Mailing Address: ao*, OL JS -tz.) HQ0
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
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)
(Riparian Property Owner Information)
aoe nIQ Nat
Mailing Address
Signature

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIERIMOORING PILINGSBOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to —1�6,A ArA.2 pc,,� 's
(Name of Property Owner)
property located at 4 O :S T
(Lot, Block, Road, etc.)
on CAt4pA L 1 fJT"5 , in `�. 5r= C-VT`? , N.C.
(Waterbody) (Town and/or County)
Applicant's phone #: ci W- 3AA— )3C0 Mailing Address: a.Ota OCD 0S 430 H u0V
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.)
?G I do not wish to waive
x_� 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)
(Riparian Property Owner Information)
QOCI S tial NLI-),?
Mailing Address
Signature

A�
7A
r
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
el F. Easley, Governor Charles S. Jones, Director
Authorized Agent Consent Agreement
William G. Ross Jr., Sec
iiNT1 s l ( ) Uf YA=k 1=1c1&� is hereby authorized to act on my beha
(Printed Name of Agent)
�r to obtain any CAMA permit(s) required for the property listed below. The authorization is limited to t
c activities described in the attached sketch.
TION OF PROJECT:
ERTY OWNER MAILING ADDRESS:
L
�Sf 3y PHONE NO. �1b - �,��' 1-300
)RIZED AGENT MAILING ADDRESS:
:6 ►
PHONE NO. �j1D- 3ak?- 31Y7S

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f, ,.,..___,.—_-- -.--.,....._....--...._ ---- - __.___ ss'

Acant: �� h 0 N S
Permit #: 5 7S/
,tribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
nd 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)
cc)
Dredge ❑ Fill ❑ Both ❑ Other ❑
�2�
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 ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

Bankof America. ��
ANTINORI CONSTRUCTION ��
145 VIRGINIA LANE ACHR/T0530001go
SNEADS FERRY, NC 28460 66-19-530
[phone]
PAY TO THE
ORDER OF: A• r
T,. --at))vn/j?Fn A nl /0
MEMO 1 Ol \ V I -J (1�
AUTHORIZE iGNATUP
1100093 131" ':053000 L961: 0006505 2 L9900

■ Complete items 1, 2, and 3. Also complete A. Signature
item 4 if Restricted Delivery is desired. ,/ ❑gent
■ Print your name and address on the reverse XL
so that we can return the card to you. - ddressee
■ Attach this card to the back of the mailpiece, B. Received by (Printed Name C. D e Delivery
or on the front if space permits. f✓
1. Article Addressed to: D. Is delivery address different from item 1? Yes
If YES, enter delivery address below: ❑ No
A N1J1 iE ". OvT lAt�
33 q FY A SA M.S5 RTN
'6RR,j ) IAc. aF53w
3. Service Type
Certified Mail ❑ Express Mail
❑ Registered ❑ Return Receipt for Merchandise
❑ Insured Mail ❑ C.O.D.
4. Restricted Delivery? (Extra Fee) ❑ Yes
2. Article Number (T7008 01 J L L::.....(Transfer from service label)
PS Form 3811, February 2004 Domestic Return Receipt 102595-02-M-1540 ;
■ Complete items 1, 2, and 3. Also complete A. Sign ture � _
item 4 jf, Restricted Delivery is desired. X K Agent
■'15kht your'name and address on the reverse ❑ Addre
so that we can return the card to you. B. Received by (Printed Name) C. D to of I
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
1. Article Addressed to:
M. z5flMcs "Owz!q'�'D
GIP", )AC C. a? - 9
D. Is delivery address different from item 1?
If YES, enter delivery address below:
3. Service Type
Certified Mail ❑ Express Mail
❑ Registered ❑ Return Receipt for Merchandise
❑ Insured Mail ❑ C.O.D.
4. Restricted Delivery? (Extra Fee) ❑ Yes
2. Article Number 7009 0960 0000 6030 9597
(Transfer from service label) _
PS Form 3811, February 2004 Domestic Return Receipt 102595-02-M-1540