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�010 11:ag FROM:MARITIME BUILDERS 9105458222 T0:18039311448
CI< 1 1EiD [L — N M-021 F1 V E,
DIVISION OF COASTAL ?tLdL % ►GSlvll -r
ADJAMNT RTPARIAN FROPlrtil"Y OWNFIRSTATRN'ZN'T
I hcrcby ocray that I own property adjacent to A&I002 /`?&Y~— M _
(Autos of property ow=r)
located at
rr�
LMi UU'a
P.1/1
in (Let, Block, Rood, etc.)p N.C.
(Waterbod (Town and/or County) I r AleApplicgnt'Sphounit: Gj'I1-_1-3xL _ W1 �drm
L A2610Y
gtF,bo lras dC=ibM-d to me 85 shown below tic develom=t hdsbe is prWWW9 W awt location.
and 1 have no objections to Lire prop09111.
ARSCRIPT1ON ANMRDRAVANG OFPROPOM DRYEIAPIISMI
(IndWunl p oPa Wg developffwAt atltsf, jilt i1f desfftsUn below or a &W* a silt drwsialg)
If you have objwtlow ro what is belaS proposal, you roast petllzy the DN Uian of Coaam pdruarcmeet MCM) to %vtlfint;
Within ib days of receipt of this rrotiee. Corre"ookgec SkogM be spatted to 127 Cnniinat mire Psis_ Wil►eio611on. KC
DCM forassntatives can *Is* be epataCft!d at (910) 794.12151
■a resgogge it 1Rf11[ dare i `Ili! SAMe, ae na 9AIMvNeer if trW! Lrr�rc zeM A411 red by Certified M"
(property Owner Int iorqultlpa
Print or Type Neme
Msi* Address
City / Stato / zip
"telephone Number �i � 2 41.0
(Ripeness PrewA0woer lafomm ion
U
�.
411M
Print of Typc Nnmo
M aiitia Address
Ml.i�i d w--6 • mac- 9` Z L
City, Seta / Zip
Te:tephana Number -d 2 _ / () C
Dote
t 27 Cwdinat 0" 9A. W1ffl ntne►, M04h CaDfi= 284O& M45
Phom 911)-79&7215 t FAX 910,39S396111ntamet'_ w1Yw-nOco26t91ma:nag mW W

A
Nas
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue James H. Gregson Dee Freeman
Governor Director Secretary
AGENT AUTHORIZATION FORM
Date: D
Name of Property Owner Applying for Permit: Nam of Authorized Agent for this project: ZLlle
Owner's Mailing Address:
Phone Number M) ?oZ Li
Agent's Mailing Address:
I�L.ea r 1�7s_ /-- Q.eQ -A
/VC ?I
Phone Number (I�D) g �/02 �3 d-a S`—
I certify that 1 have authorized the agent listed above to act on my behalf, for the purpose of applying
for and obtaining all CAMA Permits necessary to install or construct the following (activity):
(my property located) at D12 NiI'mfnc
This certification is valid thru (date) 4
Propert�Ow erSignature Date

icant: �2 /'y L C�'lj��!/ Permit #:
tribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
id in your Habitat code sheet.
itat 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/o
temp impact
amount)
Dredge ❑ Fill Both ❑ Other ❑
S
S
Dredge ❑ Fill ❑ Both ❑ Other
(!w (/
�Q
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 ❑
■ 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:
A .A . .
A. St lure /
J') ❑ Agent
X // ❑ Addressee
e ed by ( led C. Date of Delivery
D. Is deliverAddress different from item 1? Yes
If YES, enter delivery address below: ❑ No

MARITIME BUILDERS, INC. 12-06
77 CONCORD ST.
OCEAN ISLE BEACH, NC 26469-7633
!HE
ER OF
66-19/530 NC
DATE 2210
OLLARS a
6nkofAmerica
ACH R/T 053000196
�_•r-'ram-� _..____
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