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NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
ael F. Easley, Governor Charles S. Jones, Director William G. Ross Jr.. Se
Authorized Agent Consent Agreement
_f�wr»0Q1 CcA. ti'O :CK rC:J is hereby authorized to act on my behr
(Printed Name of Agent)
er to obtain any CAMA permit(s) required for the property listed below. The authorization is limited to
is activities described in the attached sketch.
kTION OF PROJECT:
FO Lc N 75�- -4-, LAy- D 1 )-AF,
'ERTY OWNER MAILING ADDRESS:
MC\/1C,.\Z t j
,aS,4(�,D PHONE NO. q jr) --5.1,o ejfi?
ORIZED AGENT MAILING ADDRESS:
PHONE NO. (llp- 3 -2) - 312,�r
.-, ., - /a( % ,- f A

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIERIMOORIIVG PILIIVGSBOATLIFTBOATHOUSE)
5 VA EarD6 V--Elnz�
I hereby certify that I own property adjacent to ;'Tl A;�t f5Z,'S is
(Name of Property Owner)
property located at 3 i G FQ ." rPS t AAF)o f 1-16 D
(Lot, Block, Road, etc.)
on Nt=_.1� Q.1-1�_ in 6ME--P0 , F S%2, , N.C.
(Waterbody) (Town and/or County)
Applicant's phone #: q to Mailing Address: 1l.2 m IW I CAP
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.)
*1
x I do not wish to waive
I
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 (Riparian Property Owner Information)
for Permit)
Mailing Address Signature

C Division of Coastal &19t. Habitat Impact Computer Sheet
plicant:&QUW (,l>�-e Permit #: P5i(VH
ate: 31)
scribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
ind 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.
bitat 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)
temp impacts
amount)
as
asp
Dredge ❑ Fill XBoth ❑ Other ❑
Dredge ❑ FilIX Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
O
' 1 go-
Dred e ❑ Fill ❑ Both ❑ Other
■ Complete items 1, 2, and 3. Also complete
item 4 if Restricted Delivery is desired.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
1. Article Addressed to:
$ Aeq Z5 VAeZAAQ
Kc-tZRC
ow °-
T, -es
1 %o1a sY1 A7L SEMI G c C,1=�sT,c e
DALE/GH,
A. Signature
X ❑ Agent
❑ Addressee
B. Received by (Printed Name C. Date of Delivery
eMW
D. Is del' • m it"
If Y ,enter deli d 13
MAR 0 2 2011
3.
Mail
' ❑ Registered
❑ Insured Mail ❑
4. Restricted Delivery? (Extra Fee) ❑ Yes
2. Article Number
(Transfer from service labeg 7008 0150 0000 5544 5349
PS Form 3811, February 2004 Domestic Return Receipt
Dredge ❑ Fill ❑ Both ❑ Other ❑
102595-02-M-1540

ANTINORI CONSTRUCTION
145 VIRGINIA LANE
SNEADS FERRY, NC 28460
[phone]
Bank of America
ACH R(T 053000196
66-19-530
7/ q h&j
PAY TO THE C �7 $ qoo
ORDER OF:
MEMO c( Lt
111008999il' j:0 5 3000 L96i: 0006 50 5 2 1990,10
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