57494D - Rogers

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NCD NR.
North Carolina Department of Environment and Natural Resources
Division of Coastal Management Dee Freeman
;verly Eaves Perdue James H. Gregson Secretary
Director
overnor
AGENT AUTHORIZATION FORM
Date: -1 I
ime of Property Owner Applying for Permit: Name of Authorized Agent for this project
- �4s O za�Imm
Nner's Mailing Address:
eF
hone Number (70U) (a 99
Agent's Mailing Address:
0.Y1 S O m�^�� r o V e Men S
�d
l� 9
Phone Number
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):
;my property located) at
r o7-L R
This certificatigw\is valid thru (date)
11
Property Owner Signature

A MAIL
CERTIFIED MAIL RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER STATEI�IE�iT
fame of Property Owner:
(Lot or Street #, Street or Road, City & County) 1 `
(' "I Mailing Address: l� o o � I� t e R a Gt `1
1pplicant s phone # 1 r�
hereby certify that I own property adjacent to the above referenced property. The individual applying for this permit
,ias described to me as shown on the attached drawing the development they are proposing. A desertion of drams
with dimens ns must be rovided with this letter.
I have no objections to this proposal. I have objections to this proposal.
If you have objections to what is being proposed, you must notify the Division of Coastal Management (DCM)
in writing within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive Eat
Wilmington, NC 28405-3845. DCM representatives can also be contacted at [phone]. No response's
considered.the same as no obi,cdon if you have been notified by Certified flail.
WAIVER SECTION
1 understand thata.pier, dock, mooring pilings, breakwater, boathouse,,or lift mint beset back a minimum distance o
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.)
Lddress of Property:
I do wish to waive the 15' set back requirement.
I do not wish to waive the 15' set back requirement.
Print or pe Name
IJ
ailing Address
�/ o
S,
(Riparian Property owner tniormatron)
Signature
Print or Type Name
Mailing Address
a (10 l l `� 0 7

ls:ls' 6T\)JJs
... ............................
IC

Division of Coastal Mgt. Habitat Impact Computer Sheet
icant: �; <o Permit #-
.vibe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
d in your Habitat code sheet.
TOTAL Sq. Ft.
FINAL Sq. Ft.
TOTAL Feet
FINAL Feet
(Applied for.
(Anticipated final
(Applied for.
(Anticipated final
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
disturbance.
tat Name
Choose One
includes any
Excludes any
total includes
Excludes any
anticipated
restoration
any anticipated
restoration and/or
restoration or
and/or temp
restoration or
temp impact
temp impacts)
impact amount)
ternimpacts)
amount)
f J
Dredge ❑ Fill ❑ Both ❑ Other
C)
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Other
Ism"
only;mestic Mail
m �• •
— ED
AFee
tage $ i0.88 0470 — �
f— Postage $
Fee $2.85 14 m
Fee Postmark ru Certified Fee
lrad) Here 0
Retum Receipt Fee
DeliveryFee (Endorsement Required)
red) $0.00 Restricted Dellvery Fee
ees O (Endorsement Required)
$ 63.73 09/21/2011 ro
Total Postage & Fees $
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rx No. a 5 (J �J� O Sireef, Api No.;* -- --- v v- — l
-(----� �_ for,
Ciry, sra{e, Z/P+4
3800. August 2006 141'
Dredge ❑ Fill ❑ Both ❑ Other ❑
Ak_
$2.N 14
Postmark
0.00 Here
$0.00
$3.29 1 09/21/2011
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