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NCDENR
North Carolina Department of Environment and Natura
Division of Coastal Management
Michael F. Easley, Governor James H. Gregson, Director
Date /-� /-2 � //Q
Name of Property Owner Applying for Permit:
Mailing Address:
R lI
c4yl //1/, NL 2 75 -17
Resources
William G. Ross Jr., Secretary
I certify that I have authorized (agent) Pet rr e // Er, V to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity)
at (my property located at) /,OR ,S&2 Sufi et/v IVL .
This certification is valid thru (date)
Property Owner Signature
Pate

�..1�:.�R,��TSz;--tie �RnSr .'T� ^7 '��r�, x'?T-. •,•-.
Name 0.L Inditi-idual Applying For Permt :
Address Of Property: : / 0 � ��& a, . 11,�-
`'U r
�
C, 4y
L
(Lot or Street
,
Street
14 or Road,C_�.
' `y & Count,.)
I hereby certify that I own property adjacent-
referenced property. The individual analY-ng for thi;Y - the above -
described to me as shown on the attache s 'Perm -It has
d drawing the they are r nrot,osing. A description or drawing,
should be provided with this letter. develonm=_n*_
W=th ` dimensions,
2�1_1 I have no ob j * '
JeC�ions to phis Proposal.
'o
r
1 uaderste,, . tint .a a
h�o�me�� I. L Pier,
doct, .maaring pilings, brea.rwat
ar./�i.7e or -boa, ��.�t
}.. be
set brch
mj' yea Of _ipa._ fan
access
- LIL�ess
d_a-. a f GQat
c a" r AID. 4 � e a_ � __ am
waive the ae::nacG •
you muss
xitial
Wa-vad. Dv . e. (T-
you. wish
the to
`apropriete b1en.1: beiaa* , }
�''J • ._ 'I do
wish to waive `..he s_c-.,«�i,� - ,_=oaui,-omens
.
_ ? IiOL-n.�.
wish
to waive
the Z3 1 setback
Tegcizem=_nt_
0
Sign Nam

'ate nAPPiying For Ps.'~mit : i? C C" 4-5
4d-Ma9 a! r7 QP9: ty ; II S -/�- a C. Q; '3
(Latt or str"z Stxz�--e1, or Road, Ci-
�;
hereby cs=;Lfy tt.at I own=vplr;,y sdjaGeut tz the :, ve-
'_fcraaced trOpe.-tv. The iadiv3,3u&l appiyiD; far `h:s permit hab
Astri.bed to mpt as ah� on the at Whed draV�n3 the deuc:C.c a :
-b'ey are ?xOP4$iMg. A descriptiou or dsawi.ng xi.-.h, diras�usians,
'Inoulµ x provided with ;,3i: 5 iet_e:.
Objectiaac to this prcYasal.
Y.2.+..1�...r :.
a
rrJkl
r ` 1��.�-....
R e�iti��r-M f n� ��
--
vrs�i ks�e,.
t own n�` j-F:.�
� --l;Y a"t�.f�„ad�aal
'a�i�d �5.�
.a pie:,
dock, .araar±aq gili.a��,
bteakr.�at�, baat +
Utz r, boat lift
Mit be
!et back r mitt= dixtmmcla
a0
aria o� _;, �iaa
ac^^..e�sa
tsrlesa wa�vad by .ue.
(I yoL V+ Xj: :o
the appW •''ate
WAnk aeloa. )
do tom. cA to
wa,+ ;ra
I +.......n" widl to pia'-•v'e the

C Division of Coastal Mgt. ^^Habitat Impact Computer Sheet
plicapt: K f vvr, 4i %V`c Cr. wf Permit #
te: -Z/q /I
q (" 5('V lt, 4 1
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)
FINAL Feet
(Anticipated final
disturbance.
Excludes any
restoration and/or
temp impact
amount)
Dredge ❑ Fi1X Both ❑ Other ❑
5
5
Dredge ❑ Fill Both ❑ Other ❑J�'
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 ❑

G! 71Y NC 2U45-002E
PAY C
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Bank of Amerlea
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