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Home My WebLink About57493D - Simmons v � � � �AN� �� :. �� v � I ___= ,� 4, , NCDENR North Carolina Department of Environment and Natural Resources Division of Coastal Management 3everly Eaves Perdue James H, Gregson governor Director Dee Freema Secretar AGENT AUTHORIZATION FORM Date: 2 ame of Property Owner Applying for Permit: Name of Authorized Agent for this project: wner'sMailing Address: Agent's Mailing Address: hone Number 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): of I )Ek&�.?V my property located) at I (0 (.� Phis cer)4icAgy is valid thru (date) _ R Property Owner Signature CERTIFIED MAIL • RETURN RECEIPT REQUESTED DIVISION OF COASTAL MANAGEMENT ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM 1 Name of Property Owner: Address of Property: (Lot or Street #, StrAt or Road, City & County) Applicant phone #: CWD ' 6 �i SS i� Mailing Address: I1O <.J; I ,. S 4. 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 or drawing, with dimensions, must be provided 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. Contact information for DCM offices is available at www.nccoastalmangement.net/contact dcm.htm or by calling 1-888-4RCOAST. No response is considered the same as no objection if you have been notified by Certified Mail. Imm 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 must initial the appropriate blank below.) I do wish to waive the 15' setback requirement. I do not wish to waive the 15' setback requirement. (Property Owner Information) (Riparian Property Owner Information) Signature Print or Type Name Signature Print or Type Name AAmiliniv Arlr ro AA -;I;- v A,4,4 . -- ivision of Coastal Mgt. Habitat Impact Computer Sheet nt: �j1(Y1+ih6-KJ Permit #: C) C� /J �b'y�ll )e below the HABITAT disturbances for the application. AP: values snuul i nitch the name, and units of measurement in vour Habitat code sheet. t 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 t 1 r-�doe n rill [] Both ❑ Other Dredge ❑ Fill ❑ Both ❑ Other ❑ Dredge ❑ Fill.y Both L_j tether ❑ 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 0 Fill ❑ Both ❑ Other ❑ f GRAPY LEE SIMMONS III 16 WILMINGTON ST66-679/531 . OCEAN ISLE BEACH NC 28469 PAY TO THE r\ �° DATE ORDER OF I v L `ECG oa, anon , oro C. MEMO ,:053 LOP.? 0 700019 1139 DOLLARS 7 9 n� 1 1 3 9--------- — ----- ' ■ Complete items 1, 2, and.& Aleb d iplOW' item 4 if Restricted Delivery is desired. ■ Print your narne 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: S"e-Oa ��wlcu-k E3,jFjeceivqd by Date of Delivery D. Is delivery address different fhrA item 1? ❑ Yes If YES, enter delivery address below: ❑ No B z NFay"`loD0 � i 3. Se ice Mail ❑ Express Mail g� ( / _N 0 Registered ❑ Return Receipt for Merchandise Q �"( tf1 ❑ Insured Mail ❑ C.O.D. 4. Restricted Delivery? (Extra Fee) ❑ Yes 2. Article Number- (rransferfromservi, 7009 1680 0002 3797 5130 PS Form 3811, Fet., ua, y 4uu4 Domestic Return Receipt 102595-02-M-1540 COMPLETE•N COMPLETE THIS SECTIONON DELIVERY ■ Complete items 1, 2, and 3. Also complete A. Signat item 4 if Restricted Delivery is desired. Agent ■ Print your name and address on the reverse Addressee so that we can return the card to you. B. Recely Tinted e) Date of Delivery ■ Attach this card to the back of the mailpiece, or on the front if space permits. D. Is delivery address different from kem 1? ❑ Yes 1. Article Addressed to: If YES, enter delivery address below: ❑ No Ne-+c-1, �A S4�1-re-n s "Ta 3. ;S p' Type L� Certified Mail ❑ Express Mail ❑ Registered ❑ Return Receipt for Merchandise ❑ Insured Mail 11 C.O.D.