57588D - Ocean

HCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
3everly Eaves Perdue James H. Gregson
3overnor Director
Dee Freemai
Secretar
AGENT AUTHORIZATION FORM
Date: 111111►
ame of Property Owner Applying for Permit: Name of Authorized Agent for this project:
Q69ne
wner's Mailing Address:
PO a,0x �I-L(,
()c e t/y. T4t �)t a cis , NL Z50 I
hone Number ( 51 °) I°1- r0 GC1
Agent's Mailing Address:
G&W,4_
Phone Number (T )
certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
►r and obtaining all CAMA Permits necessary to install or construct the following (activity):
ny property located) at 63 G - ! ,c - �..►c 1 �b1v�
'his certification is valid thru (date)
roperty Owner Signature Date

1ANU UtLlVtK
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORMG PILINGSBOATLIFTIBOATHOUSE)
I hereby certify that I own property adjacent to __W_-Axo~.. r is
(Name of Proper Owner)
property located at Vv OC.el,,T-ale ova . -IIR4-
(Lot, Block, Road, etc.)
on T�.�� ,1-� we � , in Fens ..L�- , N.C.
(Waterbody) r---- (Town and/or County)
Applicant's phone #: �i�� " 3�Z' �lw Mailing Address: �'"^'NV ^ v"
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 (IY) 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 w g ( _ n)
for %'rmtt) „� (Ory o...�v� w+�-r.�k.. owe✓ a, l�� �+^^�: Jt
Mailing Address _ Signature
e�,,�t

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YOUR LABEL NUMBER
SERVICE
STATUS OF YOUR ITEM
DATE & TIME
LOCATION
FEATURES
70091680000237983937
First -Class Mail
Delivered
November 17, 2011, 12:59 pm
CHARLOTTE, NC 28270
Expected Delivery By:
November 16, 2011
Certified Mail ry
' Arrival at Unit
November 16, 2011, 714 am
CHARLOTTE, NC 28277
Processed through
November 16. 2011. 12:34 am
CHARLOTTE. NC 28228
USPS Sort Facility
Acceptance
November 15, 2011, 2.19 pm
OCEAN ISLE
BEACH, NC 28469
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Division of Coastal Mgt. Habitat Impact Computer Sheet
)licant: n, e RA Permit #:
vvr t.
!e:
;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)
Dredge ❑ Fill ❑ Both ❑ Other
��
3-2�
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 ❑
x1Z-

COMMUNITY MAINTENANCE & CONSTRUCTION INC
113—B CAUSE WAY DR.
OCEAN ISLE BEACH, NC 28469
1315,
66-456-531
TO THE
PAY DATE Y
ORDER OF r 1V
FOR
DOLLARS U,e
FIRST BANL69
OCEAN ISLE CH, NORTH AROLINA
--------- pp
ii'00001315n' l:0531045681: 79100188L.n'