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AG
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NCDFNR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management Dee FrE
Beverly Eaves Perdue James H. Gregson Sec
Director
Governor
AGENT AUTHORIZATION FORM
Date: a.0 1 I
Name of Property Owner Applying for Permit: Name of Authorized Agentt for this project:
Ct on
Owner's Mailing Address:
DNA-l1o7% i✓. C � ��C 4- � a --
Phone Number
Agent's Mailing Address:
� G
2 ASP
Phone Number
horized the agent listed above to act on my behalf, for the purpose of applying
I certify that t have aut
install or construct the following (activity):
for and obtaining all CAMA Permits necessary to
(my property located) at
This'certification is valid thru (date)
--;el, n /"/A,,, 3-i

• ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to 7A4! is
(Name of Property Owner)
property located at Z�-A off" T14 &,4 5T % J 3 S ! /{i4L���
(Lot, Block, Road, etc.)
on 6/1 Z-4o2a I Y /L_ , in 1 ��4 LL�►7rF j`!, %9tmwt I c �c-3 N.C.
(Waterbody) (Town and/or County)
3"301
Applicant's phone #01c Mailing Address ] "Tg)hk 5?J
5'*44L77Vrf iV SG ;k,8 -7 o
He has described to me, as shown below, the development he is proposing at that location, and, I
have no objections to his proposal.
---------------------------------------------
---------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by property owner proposing development)
------------------------------------------------------
------------------------
(Information for Property Owner Applying (Riparian Property Owner Information)
for Permit)
:��- 14
Mailing Address
Signature
31 to l 7-14 1' 4 14q t
Lr/ L�- —r LL 2� 1�' -

CERTIFIED MAIL — RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIP—A'R-IAN PROPERTY OWNER STATEMENT
Name of Property Owner:-(d i . I t~I _
Address of Property: 3 + (2 f y-o(
(Lot or Street �, Street or Road, CityF& County)
Applicant's phone Mailing Address: 4: �' ..e.,
I hereby certify that I own property adjacent to the above referenced property. The individual applying for this pern
has described to me as shown on the attached drawing the development they are proposing. A description of drawir
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. Correspondence should be mailed to 127 Cardinal Drive F.
Wilmington, NC 28405-3845. DCM representatives can also be contacted at [phone]. No response is
considered the same as no objection if You 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
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' set back requirement.
I do not wish to waive the 15' set back requirement.
(Property Owner Information)
1�1-
Signature
7-. S� LLB S
Print or Type Name
376oi T1414sr
Mailing Address
(Riparian
Signature
A\4i A i*-e d e_
Print or Type Name
Mailing Address
Information)

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to *-7R g I 'T, SQL -_fs
(Name of Property Owner)
property located at L T -4 8 1-4 PT &/4A-clv ocs,s�
(Lot, Block, Road, etc.)
on 7I,-a CQ— l� v , in t IJ4/5,01 C k C. , N.C.
(Waterbody) (Town aid/or County)
Applicant's phone #: Mailing Address: 2 G �T44 fg�,
He has described to me, as shown below, the development he is proposing at that location, and, I
have no objections to his proposal.
---------------------------------------------------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by property owner proposing development)
(Information for Property Owner Applying
for Permit)
:31(PI -r4,28ST,
Mailing Address
LCd� to . < '- D-i 17 0
City/State/Zip
(,^(Riparian Property Owner Information)
\ ` n
Signature
Ow e n el? ✓J e

,'vV by F3l %`C\ G/v v v-

C Division of Coastal Mgt. Habitat Impact Computer Sheet
plicant: 1 � j —� "::� ( (-ells
Permit #:P SJ,
scribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
ind in your Habitat code sheet.
bitat 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)
j
i
Dredge ❑ Fill ❑ Both ❑ Other �(
l a i
1 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 ❑

GRICE CONSTRUCTION OF BRUNSWICK
COUNTY INC
6618 BEACH DR SW BS. 910-579-9095
OCEAN ISLE BEACH, NC 28469-4710
�Y
THE
IDER OF c 14 KI 1
BRANCH BANKING AND TRUST COMPANY
1-800-BANK BBT BBT.com
'i'0000 788 9n' ':O S 3 10 1 1 2 11:000 S L 9 9 9 2 6 S 2 9ii'
7889
i 66-112/531
DATE
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