76091_Jerome Costa_20200716

BGAMA/ ❑DREDGE & FILL ��.;}Co Lo 59
No. 76091 i
G NERAL PERMIT -tT Previous ermit# A ® C D
MNew ❑Modification ❑Complete Reissue UPartial Reissue p �/�
Date previous permit issued _,.,..��
As authorized by the State of North Carolina,Department of Environmental Quality
and the Coastal Resources Commission in an area of environmental concern pursuant to I SA NCAC 0 7/4 4.2 e(/
I3r9Tes attached.
Applicant Name je f(.' e f 4 Project Location: County 4'64 0,‘-7/
Address_ 4'O2/._LQ�lntira V.,- 4• �z -- Street Address/State Road/Lot#(s) /,5/Q id,//7
City_Ze ,X,�y"n i State/I/C ZIP 7/PG V o 1` Jg 79 ---
Phone#(2S,Z) 1aJ-.3'017 E-Mail „id Subdivision ,,/.//,4 '
Authorized Agent ✓'I �G.-,sc 6�/�_e•I•ti City 4 A 4'vll
ZIP ����U
Affected IAA DEs [1 PT5 Phone# r j
(_ ) River Basin /G /�,.,
AEC(s): IDEAO HHF L71H ❑URA ❑N/A //��
D pyys. Adj.Wtr. Body /may,F.G v 4,-„/ (nat /man /unkn)
ORW: yes / no' PNA yes no Closest Maj.Wtr.Body .l 1-•!+ •c_ ,vr_�'
Type of Project/Activity ri '
Gomm, 1/,/f l J',1 /� ' «., ..2 r,o,,. �. �,�4 r�i0—
Pier(dock)length_ /d5'... /'` J `� r A. t f�/ (State: / �a
Fixed Platforms Y e r�
Floating Platform(s) i f { l i �- __ -
Finger pier(s} - ,/; , _. _
Groin length --- , : ; -1 t f--'--'r-� -tr - I 1 i �1 -• J -^-i �_
number 11 ii I I -i
Bulkhead/Riprap length !- i 1._. I }
{
avg distance offshore i . I �j iT j L a.- T. l.. -- 1_+_! I .t � 1 l _
max distance offshore .. + �1 , �(_ __ - _ f _ I f
i— i , lam - 1
Basin,channel-- -- ! I 1-Q- as �' 1 I
, i
cubic yards ) ;-- -- � `-'-'
.__- , f - _ --t I -_
Boat ramp - t t i I / - I _ _ I ; --- -I-+..._
Boathouse/Boatlih JS `!`/J + j ! . -
Beach Bulldozing_ + I �ii �— i
I I I
i i
Other _ - ----• • - ' ' ! I i- 1 l - , —
, ! 1 , fe,,s ,,,i tc,„e_, ..__ _, ri././i I 1 /,.),rt. t_ _
Shoreline Length_ ,Gle + �l _ �, y
? I • {_.
Ztonu ! ;
LsJ (ge -/ i - 1 6-CP i i _ 1-- _
Photos: ! �_ _ i
yes ,,i I i �- - — I 17 :--
, I _
i � �
Waiver Attached: yes . � 1 i , . —!_.
IH
// /" / ,—,
A building permit may be required by: gar, r�- o glee note on back regarding River Basin rules.(Note Local Planning Jurisdiction)
Notes/Special Conditions .ce•e_+ (.�7/]. /29n
4
•r pp6 n •rinte.' .me D -- - SL1Cre6 / //
/ PermitOfficer's Printed Name____ ,___ ___...-:,____ _.„-_- -
Signatur Please read comp lance statemen on back of permit** Signature/ ,
Application Fee(s) -- `- _ �'�� --- ,-
Check# Issuing Date Expiration Date

MA/ ❑DREDGE & FILL No. 76091 A O C D
e
►❑'LAGENERAL PERMIT Previous permit#
�/,�
)C L New ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued _r/ X¢
As authorized by the State of North Carolina,Department of Environmental Quality
and the Coastal Resources Commission in an area of environmental concern pursuant to I SA NCAC 0 77--. /,—d!, .
L 1 es attached.
Applicant Name je 'o +''e .(14 Project Location: County fft4u / —/ta
Address /j22/ z,,_x ,� ✓.„- 4.‹.-rL Street Address/State Road/Lot#(s) /5/0 ,11ri
City /C od,A.,„i State/I/6 ZIP o2 7f' Y c 9 7/ JR 79
Phone# (,25.47) 90-7--5'0.77A�E-Mail A✓�-4 / s Subdivision ,�`LI
77 f Authorized Agent ' /"Lr.he �,,,j1i'1<71'.1 City , /h ekea ZIP .27.W0�
❑CW L►�EW E 14A ❑ES ❑PTS Phone# ( ) River Basin / ``4 f-+
Affected ❑OEA ❑HHF ❑IH ❑UBA ❑N/A //�J
AEC(s): Adj.Wtr. Body f m v el (nat /man /unkn)
❑ PWS: �
74
ORW: yes / no"' PNA yes no Closest Maj.Wtr. Body ��p `- r'
Type of Project/Activity .7.7,4 4er;2.e /0 S K b Jo;e- k.."" /4 ©`�/X�.4 / - ArrL ci"p///io:
,L 4 //7/ /7'�/J ' a., r�oor,'ti f �.�i c«l r� 4 r f/c 4..<f—.,-�j� (Scale: / '�; y(}` )
Pier(dock)length /AS- x
Fixed Platform(s) (J`? 2€ I I '
Floating Platform(s) I 1
Finger pier(s) O {
Groin length ! a i
number 3 1 ?el „t I'
Bulkhead/Riprap length ' 0- la ' I , `
avg distance offshore N
max distance offshore 0K 1�
Basin,channel G Q \k \ /'
Vf ./� 1
i fr
cubic yards - f� ( '
i / i I
Boat ramp 1
',/l ' . .I I F
Boathouse/Boatlift 3
Beach Bulldozing i
Other v/ p i i
i
�� �n
Shoreline Length MO' �SAV: Got su-r;Th yes no ---- CO1 4 4Yd a(- i
Moratorium: n/a yes <I
Photos: yes
Waiver Attached: yes 67 Li. Or , 1
I r
I 1
A building permit may be required by: �eea/��7-/ 6 . 1►ilBee note on back regarding River Basin rules.
(Note Local Planning Jurisdiction)
Notes/Special Conditions See ON/-, 72e9O
S-I_C N L /`: ✓ ` .�/ ey
Agent or Applicant Printed Name Permit Officer's Printed Name /
Signature **Please read compliance statement on back of permit** Signature
1.200 j 5,.5/,5 /6 c� .Zozo /6'Aire m,�« ,20 -O
Application Fee(s) Check# Issuing Date Expiration Date

Statement of Compliance and Consistency
This permit is subject to compliance with this application, site drawing and attached general and specific conditions. Any
violation of these terms may subject the permittee to a fine or criminal or civil action; and may cause the permit to become
null and void.
This permit must be on the project site and accessible to the permit officer when the project is inspected for compliance. The
applicant certifies by signing this permit that I)prior to undertaking any activities authorized by this permit,the applicant will
confer with appropriate local authorities to confirm that this project is consistent with the local land use plan and all local
ordinances, and 2) a written statement or certified mail return receipt has been obtained from the adjacent riparian
landowner(s).
The State of North Carolina and the Division of Coastal Management, in issuing this permit under the best available
information and belief,certify that this project is consistent with the North Carolina Coastal Management Program.
River Basin Rules Applicable To Your Project:
Tar-Pamlico River Basin Buffer Rules Other:
Neuse River Basin Buffer Rules
If indicated on front of permit,your project is subject to the Environmental Management Commission's Buffer Rules for the
River Basin checked above due to its location within that River Basin. These buffer rules are enforced by the NC Division of
Water Resources. Contact the Division of Water Resources at the Washington Regional Office (252-946-6481) or the
Wilmington Regional Office(910-796-72 15)for more information on how to comply with these buffer rules.
Division of Coastal Management Offices
Morehead City Headquarters Washington District
400 Commerce Ave 943 Washington Square Mall
Morehead City, NC 28557 Washington, NC 27889
252-808-2808/ I-888-4RCOAST 252-946-6481
Fax: [phone] Fax: [phone]
(Serves:Carteret,Craven,Onslow- (Serves: Beaufort, Bertie, Hertford, Hyde,
North of New River Inlet-and Pamlico Tyrrell and Washington Counties)
Counties)
Elizabeth City District Wilmington District
401 S. Griffin St. 127 Cardinal Drive Ext.
Ste. 300 Wilmington, NC 28405-3845
Elizabeth City, NC 27909 910-796-7215
252-264-3901 Fax: [phone]
Fax: [phone] (Serves: Brunswick, New Hanover,
(Serves:Camden,Chowan,Currituck, Onslow-South of New River Inlet-
Dare,Gates, Pasquotank and Perquimans and Pender Counties)
Counties)
http://portal.ncdenr.org/web/cm/dcm-home
Revised 7/06/17

CAMA / DREDGE & FILL . ' No. 76091 A ® C D
/
GENERAL PERMIT Previous permit# ./ 4
)C [flew ❑Modification EJComplete Reissue ❑Partial Reissue Date previous permit issued ,r7/tea'
As authorized by the State of North Carolina,Department of Environmental Quality and the Coastal Resources Commission in an area of environmental concern pursuant to I 5A NCAC 1-) '_
�77, /.lr'G7 .
131 les attached.
Applicant Name je'PO'"e �,o l h Project Location: County /J<<c, /o-v—1
l Address y/tom/ L 4,-X,0 ✓.-. /-<, e_
- _, Street Address/State Road/Lot#(s) /. /O A(7 ri
/.v City -1y, WONr) / State,V( ZIP d 7f V /7 ii ?9
Phone#(252) 9G-- &27 E-Mail --,//1 Subdivision ,ai//"
• Authorized Agent 'I f /yt.,rc f/c • (... City /s e/X e,« ZIP ..Z 7k/U,�
❑Cw c 4cv [ ITA ❑ES ❑PTS Phone# ( ) River Basin /‘- •/`!,,
Affected ❑OEA ❑HHF ❑IH ❑UBA ❑N/A //JJ /
AEC(s): Adj.Wtr. Body �h,, v G�ee�" (nat /man /unkn)
❑ PWS: ��
ORW: yes /(no; PNA yes Vno Closest Maj.Wtr. Body a,', /e�P'
Type of Project/Activity 4h,/4„„ : , l 0.:,-- 6 r. • • // -'O'^ O L /1•. ,/ .�/ //i„,
r / i/ /, . ,,,,.oc.. ��,/, /f 1 ��/ /-r� (Scale: / 'N- 7Q` )
Pier(dock)length / -f. <. _
Fixed Platform(s) -26 t' G
Floating Platform(s) N t4 V C<<4 /C
Finger pier(s) c. 1
Groin length + j{ Ii
number �" �£bw 1 y /a/i +,1 I
Bulkhead/Riprap length p ® r
avg distance offshore '^«.. ..,..
max distance offshore I I ^i/ I 144 l
Al' '
Basin,channel 0 Q \a\ \ _
cubic yards \ 1 f
Boat ramp
Boathouse/Boatlift/_ //i
. ' .) ' i - All
Beach Bulldozing
Other e
Shoreline Length /DV �' /�
SAV: C not rus e=1)yes no J / y%jy4 C
Moratorium: n/a yes no-'
Photos: yes l ►
Waiver Attached: yes (V/4
/ /' �,� __
A building permit may be required by: / G<c,f `i f ( , . tE See note on back regarding River Basin rules.
(Note Local Planning Jurisdiction)
Notes/Special Conditions ,-,-- (07//• /24)Q
,.5-7.1 e,,I /r. (-1 j/
Agent or Applicant Printed Name Permit Officer's Printed Name /
Signature **Please read compliance statement on back of permit** igS nat e .
Application Fee(s) Check# Issuing Date Expiration Date

Statement of Compliance and Consistency
This permit is subject to compliance with this application, site drawing and attached general and specific conditions. Any
violation of these terms may subject the permittee to a fine or criminal or civil action; and may cause the permit to become
null and void.
This permit must be on the project site and accessible to the permit officer when the project is inspected for compliance. The
applicant certifies by signing this permit that I)prior to undertaking any activities authorized by this permit,the applicant will
confer with appropriate local authorities to confirm that this project is consistent with the local land use plan and all local
ordinances, and 2) a written statement or certified mail return receipt has been obtained from the adjacent riparian
landowner(s).
The State of North Carolina and the Division of Coastal Management, in issuing this permit under the best available
information and belief,certify that this project is consistent with the North Carolina Coastal Management Program.
River Basin Rules Applicable To Your Project:
Tar-Pamlico River Basin Buffer Rules I I Other:
Neuse River Basin Buffer Rules
If indicated on front of permit,your project is subject to the Environmental Management Commission's Buffer Rules for the
River Basin checked above due to its location within that River Basin. These buffer rules are enforced by the NC Division of
Water Resources. Contact the Division of Water Resources at the Washington Regional Office (252-946-6481) or the
Wilmington Regional Office(9 I 0-796-7215)for more information on how to comply with these buffer rules.
Division of Coastal Management Offices
Morehead City Headquarters Washington District
400 Commerce Ave 943 Washington Square Mall
Morehead City, NC 28557 Washington, NC 27889
252-808-2808/ I-888-4RCOAST 252-946-6481
Fax: [phone] Fax: [phone]
(Serves:Carteret,Craven,Onslow- (Serves: Beaufort, Bertie, Hertford, Hyde,
North of New River Inlet-and Pamlico Tyrrell and Washington Counties)
Counties)
Elizabeth City District Wilmington District
401 S. Griffin St. 127 Cardinal Drive Ext.
Ste. 300 Wilmington, NC 28405-3845
Elizabeth City, NC 27909 910-796-7215
252-264-3901 Fax: [phone]
Fax: [phone] (Serves: Brunswick, New Hanover,
(Serves:Camden,Chowan,Currituck, Onslow-South of New River Inlet-
Dare,Gates, Pasquotank and Perquimans and Pender Counties)
Counties)
http://portal.ncdenr.org/web/cm/dcm-home
Revised 7/06/17

goCAMA / DREDGE & FILL No. 76091 A CBB C D
GENERAL PERMIT Previous permit #
)C New _Modification Complete Reissue Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
Rules attached.
Applicant Name J. ! •°e. ( c ; 1- Project Location: County
Address /`(.../% L ,- ,' v .;c - Street Address/State Road/ Lot#(s)
City State A. ZIP
Phone# (- )_ • E-Mail Subdivision
Authorized Agent / City ZIP /(--'
❑CW L9EW L9-PTA ❑ES ❑PTS Phone # ( ) - River Basin 1 - / "<•?,-,
Affected ❑OEA ❑HHF ❑IH ❑UBA ❑N/A
AEC(s): Adj.Wtr. Body _ t' r,-,./ (nat /man /unkn)
❑ PWS: z-2
ORW: yes / no PNA yes / no Closest Maj.Wtr. Body
Type of Project/Activity
(Scale: )
/
Pier(dock)length _
I
1
Fixed Platform(s) 1 1111111
-r
Floating Platform(s) _ .111. Mil .
ll
Finger pier(s) -
Groin lengthII
i r'
number ti - I
l j
Bulkhead/Riprap length • v
avg distance offshore / .I
max distance offshore
Basin,channel
cubic yards
111111
Boat ramp -
ell I
BBeachoathouse/Boatlift/ /Other Bulldozing , II NIH ilillliillliflhlll i i
j IuIHHHhIIiIIIIIIIH1HI! lIIII!I1
Shoreline Length yes no IIIIIIIiII!"!IiiiiIPIII!UIIIN■■■ ■■
Moratorium: n/a yes no i.. ,i!a.......................�...uu..
Photos: es no 2 ®A _ . 1111..... ....uu....u... MEI-111111111111
Waiver Attached: yes no r
/. /
A building permit may be required by: /,,. i . n See note on back regarding River Basin rules.
(Note Local Planning Jurisdiction)
Notes/Special Conditions
11 /
Agent or Applicant Printed Name Permit Officer's Printed Name
Signature **Please read compliance statement on back of permit** Signature
Application Fee(s) Check# Issuing Date Expiration Date

Statement of Compliance and Consistency
This permit is subject to compliance with this application, site drawing and attached general and specific conditions. Any
violation of these terms may subject the permittee to a fine or criminal or civil action; and may cause the permit to become
null and void.
This permit must be on the project site and accessible to the permit officer when the project is inspected for compliance. The
applicant certifies by signing this permit that I)prior to undertaking any activities authorized by this permit,the applicant will
confer with appropriate local authorities to confirm that this project is consistent with the local land use plan and all local
ordinances, and 2) a written statement or certified mail return receipt has been obtained from the adjacent riparian
landowner(s).
The State of North Carolina and the Division of Coastal Management, in issuing this permit under the best available
information and belief,certify that this project is consistent with the North Carolina Coastal Management Program.
River Basin Rules Applicable To Your Project:
Tar-Pamlico River Basin Buffer Rules I Other:
Neuse River Basin Buffer Rules
If indicated on front of permit,your project is subject to the Environmental Management Commission's Buffer Rules for the
River Basin checked above due to its location within that River Basin. These buffer rules are enforced by the NC Division of
Water Resources. Contact the Division of Water Resources at the Washington Regional Office (252-946-6481) or the
Wilmington Regional Office(910-796-72 15)for more information on how to comply with these buffer rules.
Division of Coastal Management Offices
Morehead City Headquarters Washington District
400 Commerce Ave 943 Washington Square Mall
Morehead City, NC 28557 Washington, NC 27889
252-808-2808/ I-888-4RCOAST 252-946-648 I
Fax: [phone] Fax: [phone]
(Serves:Carteret,Craven,Onslow- (Serves: Beaufort, Bertie, Hertford, Hyde,
North of New River Inlet-and Pamlico Tyrrell and Washington Counties)
Counties)
Elizabeth City District Wilmington District
401 S. Griffin St. 127 Cardinal Drive Ext.
Ste. 300 Wilmington, NC 28405-3845
Elizabeth City, NC 27909 910-796-7215
252-264-3901 Fax: [phone]
Fax: [phone] (Serves: Brunswick, New Hanover,
(Serves:Camden, Chowan, Currituck, Onslow-South of New River Inlet-
Dare,Gates, Pasquotank and Perquimans and Pender Counties)
Counties)
http://portal.ncdenr.org/web/cm/dcm-home
Revised 7/06/17

NC Division of Coastal Mgt. /Habitat Impact Computer Sheet
Applicant: le r ap-1 e C.--eS 1`
Date: /6
General Permit#. 7�D 7 I //
Describe below the HABITAT disturbances for the application. Ali values should match tie ,lame,and units of measurement
found in your Habitat code sheet
TOTAL Sq.Ft ANAL Sq. ft. TOTAL Feet ANAL Feet
(Applied for. (Anticipatedfiral (Applied for. (Anticipated final
DISTURB TYPE Disturbance total disturbance Disturbance disturbance.
Habitat dame includes any Excludes im ! total includes Excludes any
Choose One
anticipated restoration any anticipated restoration and/or
restoration or and/or tern p restoration or temp impact
temp impacts) . impact amount.) i ternp impacts) amount)
age? 11//e". Dredge❑ All❑ Both ❑ Other 27- 1 pt/ 7g 4
Dredge❑ Fill❑ Both ❑ Other ❑
Dredge❑ Fill❑ Both 0 Other ❑
Dredge❑ Fill❑ Both ❑ Other ❑
• Dredge❑ Fill❑ Both El Other ❑
Dredge❑ Fill❑ Both ❑ Other ❑
Dredge❑ Fill❑ Both ❑ Other ❑
Dredge❑ Fill El Both 0 Other ❑
Dredge❑ Fill❑ Both 0 Other El
Dredge❑ Fill❑ Both ❑ Other ❑ I(
Dredge❑ Fill❑ Both ❑ Other El
Dredge❑ Alt❑ Both ❑ Other ❑
Dredge❑ Fill 0 Both El Other 0
Dredge❑ Fill❑ Both ❑ Other ❑
e(0�
36
Cter
lG S

whordzed Ag-eni Coreseng Agreerigeng
los-L
herby authorize Tobin Jay Tettert.to of
(Property Owner(s)
TJ's Marine Construction LLC to act on my behalf in obtag CAW permits for
be location listed below.
PROPER'fY ADDRESS:
ISIt Hog' ilSt-•
C., 27IO
PROPERTY OWNER'S MAILING ADDRESS:
11162 ve4,
Phone
PROPERTY OWNER'S SIGNATURE':
AUTHORIZED AGENT SIGNATURE:
OEJ TETT RTON
DATE:_itAl 24p
VV/Authorized Agent Consent Agree.

DocuSign Envelope ID:B7A45857-8DD0-4A2D-B81D-500A84B8C5B1
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to J€c c,;,-,fir , 0 n c_ C_-.,< ; 1
.s
(Name of Property Owner)
property located at /iS/ j (a 1 (- 42. a c A
(Address, Lot, Block, Road, etc.)
on_ \-!.•Ap ( 1'C.C. K. .in 3 a' li .,v.f v\
(Waterbody) N.C.
(City/Town and/or County)
The applicant has described to me. as shown below, the development proposed at the above
locati
I have no objection to this proposal.
I have objections to this proposal
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
r
r C.- 1 /nO0/i''5- �./n�
/.,7 5'(/)
I -I L, i
WAIVER SECTION
mooring pilings. boat ramp, breakwater, boathouse, lift. or groin
istance of 15' from my area of riparian access unless waived by
tback, you must initial the appropriate blank below.)
the 15'setback requirement.
r . � _ I
t CCJ give the 15' setback requirement.
(Adjacent Property Owner Information)
s wt:4.. �_:,:..War,.....
�aumIFu,c
,[ Signature- {,
Prrr�or T(A�L.i^,r) :l n�' Co5! 5�s`r Ci s'! (t ;a t_ Iv �i/r c h-S
,4.,y/. ,Nam l 1 Print or Type Name
f�i' :i)/�4 L 6 yc3 1c' a l (l i.l,_) _5-2 T 1
fi Address f �.,,JJ
)c ue. Ae 4;2-
coistegegyo ,r...- Tye:, ,•- �dr-'u o Mailingddrey= t
Z 2- 9 J S,0 city, areJ7,p ,
owi f0Number r em %pyL$h• Taieph 020 ! 6/
NumOer email Ore,ss 0
Pa h'
Dar, -
`Valid for one calendar year after signature' (Revised Aug.2014)

DocuSign Envelope ID:BA6B989F-BCB0-4A0B-86D2-4D74D606327B
ADJACENT RIPARIAN PROPERTYTT-- OWNER STATEMENT
I hereby certify that I own property adjacent to ✓�,rinrw4 ! A n C.1)544-- 'S
(Name of Property Owner)
property located at !S/0 °44 ao
ccnc, a (Address, Lit. Block. Road,etc.)
on
.1 t'ee rr . in t442/AgV Q� . N.C.
(Waterbody) (City/Town and/or County)
The applicar has described to me, as shown below, the development proposed at the above
location
have no objection to this proposal.
_ __ I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposingdevelopment must fill
In description below or attach a site drawing)
r 0, boc..- I..c o? /1166/; p'/VC5
hIsli-) fif
WAIVER SECTION
! understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse. lift. or groin
must be set hack 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) (Adjacent Property Owner Information)
��i+.b a...y,..�, _
` /F P.
` tiltUtr
` """wee...•
90
r elute :` ,
r .Signature _,I
k1rob,e ' 4hrc.., l o5 e, -1imm4l V � 1f� h 6e, it^
Pant ar ry Nsmw Print or TP Name
Ln
la° ri?cr4e-s. Q.A ./CI 0 6 yy3 4 ieic,lihngrAddlaw...4.. �� ddtcss1✓G1`Ids�.� NC1 e 1 oyy p I103 S 0.Z Crr Starers pItia �1 .
Te�epphome Number i vrr�atl addro�r Teiep ne Number email Address
6/14/2020 /114/ZOZ6/14/2020
IJcrc anc•
/Revised Aug. 2014)
'Valid for one calendar year after signature'