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N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date
Name of Property Owner Applying for Permit:
Mailing Address:
I certify that I have authorized (agent) 1 J l� to
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)
This certification iswalid thru (date)
7,

CERTIFIED MAIL —RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
Name of Property Owner:MA�t dr'T/I i
Address of Property: ke-y Jhy /7�dw� & a, /v G
of or Street #, Street or Road, City & ounty)
Applicant's phone #: {/d' Q�3b7-oZS�(J Mailing Address: aS yW Q�,h- 3.�L
I hereby certify that I own property adjacent to the above referenced property. The individual applying for this
permit has described to me as shown on the attached drawing the development they are proposing. A description
of drawing. with dimensions. must be provided with this letter.
- l 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
Ext.
Wilmington. NC 28405-38 d5. DC NI representatives can also be contacted at [phone]. No response is
considered the same as no objection if Iou have been notified by Certified
Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, or lift must be set back a minimum distance
of 15' from my area of riparian access unless waived by me. (If you wish to waive the setback, you most initial
the appropriate blank below.)
I do wish to waive the 15' set back requirement.
I do not wish to waive the I-' set back requirement.
(Property Owner Information) (Riparian Property Owner Information)
G
Signature Signatur 1 llln

CERTIFIED MAIL —RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
)f Property (honer:
s of Property
Lot or Street,-?. Street or Road. City & County)
tnt's phone : �4/0 3,- -c;2S3G,� Mailing .Address: 1,;S IM)
_ - ,dj- ijo-ld/►'1ar�>f+-e-� 61`'r /mil ,416
,�) T'y<z
iy ceriifi, that I own property adjacent to the above referenced property. The individual applying for this
has described to me as shown on the attached drawing the development they are proposing. I description
vino «•itli dimensions, must be provided with this letter.
A 1 have no objections to this proposal. 1 have objections to this proposal.
have objections to what is being proposed. -*,on must notifti• the Division of Coastal Management
ting ,oithin 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive
noon 1C 28405- 84.1. DCM representatives can also be contacted at [phone]. No response is
Bred the same a5 no ahk('tirrn if }•ou baf a been no ' led hs- Certified
WAIVER SECTION
rstand that a pier. dock. mooring pilings. breakwater. boathouse. or lift must be set back a minimwn distance
from my area of riparian access unlcss waived by me. (if you wish to waive the setback. you must initial
propriate blank bclow.)
W1 do wish to waive the 15' set back requirement.
I do not wish to waive the 15' set back requirement.
ertN O,,cner Information) iparian Property -ner Information)

Division of Coastal Mgt. Habitat impact Computer Sheet
cant: ' Permit #:
tribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
d in your Habitat code sheet.
tat 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
5 o
S L
Dredge ❑ Fi Both ❑ Other ❑
50
Dredge ❑ F, 6 Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other
Dredge ❑ Fill ❑ Both ❑ Other ❑
I
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 ❑

(TO THE
DER OF_
ALLIED MARINE CONTRACTORS, LLC 08-03
910-367-2159
92 HAROLD CT.
HAMPSTEAD, NC 28443
4752
66-19/530 NC
702
/I I
A
m
0
DOLLARS 6
c
es N
J 1 �
11'004752118 C0530001961: 00068474373g T"o EDSIGNATURE
FIVE
Bank of America
ACH R/T 053000196

■ 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:
R (r , T� y 1 �' r
a�33�
A. Signatu
X 7 �(JJ/ ❑ Agent
'e�X� ❑ Addressee
B. Re eiv by ( Printe�►arne/) C. Date of Delivery
D. Is delivery address diffe�nt from item 1 ? ❑ Yes
If YES, enter delivery address below: ❑ No
3..S,eice Type
YJ Certified Mail ❑ Express Mail
❑ Registered ❑ Return Receipt for Merchandise
❑ Insured Mail ❑ C.O.D.
4. Restricted Delivery? (Extra Fee) ❑ Yes
2. Article Number
(Transfer from service label) 7 011 0110 0000 0551 1670
PS Form 3811, February 2004 Domestic Return Receipt 102595-02-M-1540
■ 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.
IN Attach this card to the back of the mailpiece,
or on the front if space permits.
1. Article Addressed to:
W , IAA
i l\
At. 3idnature
❑ Agent
t k -J ❑ Addressee
�. Receiv d by (Printed Name) C. Date of Delivery
D. Is delivery address different from item 1? p Yes
If YES, enter delivery address below: ❑ No