56559D - Besedin

AAA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
arly Eaves Perdue James H. Gregson
ernor Director
Dee Freeman
Secretary
AGENT AUTHORIZATION FORM
Date: ,? 5 c
e of Property Owner Applying for Permit: Name of Authorized /Agent for this project:
Mailing Addressi
Agent's • `.•
I
/ M
ne Number (31-(2 ) e-/, ///' Phone Number ( 0)5ff2l- `>
rtify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
and btaining all CAMA Permits necessary to install or construct the following (activity):
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. ..- . -. . `.:.� L..1/ice
'1�
is certification is valid thru (date) /�,7
/ 5-h
Property Owner Signature Date

06.2010 04:31 PM
PAGE. 2/
:GUY C LEE/SNEADS FERRY FRX N©. :91032723G7 Dec. 83 2010 02:06PM P2
ADJACENT RIPARIAN PROPERTY OWNLR STATEMENT
(FOR A-PIF,R/110OR1,VG PILI'VGS/$OATLIFrIBOAT,90(iYE)
r hereby certify that I own property adjacent to 6
' p �A gnae of Property
Property located at ��- (]caner)
Oil(�Wa t 18 r b zoa
in
,Road, etc.)
—, N.C.
ink i r
(Town and/or County)
He has described to me, as showtl below, the development he is proposing at that location, and, I have
no objections to his propoSW, [ understand that a pier/mooring pilings / m minimum distance o(boatlift / boathouse must be set
fifteen feet 05') from my area of riparian access unless waived by me.
back
(If you wislw to waive the setback, you must initial the appropriate blank below.)
I o not wish to waive !!/�.�' Se T Aff'*a r9 rW14''�i� ©� g'4
I do wish t4 waive that setback requirement,
-- ...............
---------------------- -.............
DESCRIPTION AID/OR BRA
WING OF PROPOSED I)MLOPMENT: --
(To lie filed In by individual proposing development)
101 is (To
(,� : -� U-�W lk u>r,y T t�
019 4�1 w J k- to ] q x ,p b j,s kf
Rove 5 t ; P-5 ry o 7*rv0r'V,`,t
If you have objectianu to what is being PrOPOSed,you ust �"-""-
w►thin lU dayA of recxipt of this notice, Corresponden osho should ba ma�itedsto xZ7 Carolina Drive Linagement )CM)onwNCllg
UCM reprosontutives can also be Contacted at [phone]{
'v e IRS-9usi Jered t m ob !nn if y
blen not
(information for Property Owner/Applicant (Riparian Property Owner Information)
Applying for permit)
Mailing Adcisess �•,_*v" _
�"%dv/7 L�► bi' /Cl Il � � Sig�ture
City/State/Zip

DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to I q_:!� Q
(dame of Proper Owner)
property located at t0 / 1 ✓ '
n i (Lot, Bl ck, Road, etc.)
(� h , in �u/ 41 1%P � _, N.C.
on � � � aterbod Q� -- (Town and/or County)
(w y) / / l 8 S �Ye�/e�,
Applicant's phone #: �� .j ��9 �f ���Mailin Address:
He/She has described to me as shown below the development he/she is proposing it that locution,
and I have no objections to the proposal.
-------------------------------------------------------------------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(Individual proposing development must fill in description below or attach a site drawing)
'r'� I ole 6 �r c� ' a � 1�,41k-t�1.4) % A
121 k 20 &,t-Z,6(3c'
If you have objections to what is being proposed, you must notify the Division of �_oastai ivianagCiiiCut �,,. ,.,� ILL TV A
within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive Ext. Wilmington, r
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
(Property Owner Information)
Signature
M 0 I F i3 efed l,�)
Print or Type Name
l07IF �i �dE'��P�� L,&)
MailinE Address
(Riparian Property Owner Information)
Signature
Print or Type Name n
fn7­2 Q VIM --
Mailing Address

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C Division of Coastal Mgt. Habitat Impact Computer Sheet
)plicant: owl"" 9- VcGn
ite: �' /o ilO
Permit #: q P 5Co55'
ascribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
and in your Habitat code sheet.
ibitat 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/c
temp impact
amount
W
Dredge ❑ Fill ❑ Both ❑ Other
22 (j
zz�
Cw s
Dredge ❑ Fill ❑ Both ❑ Other
3(0
Dredge ❑ Fill ❑ Both ❑ Other
So
1 Sn
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 ❑
FOR

THOMAS POWER SYSTMES INC.
128 SILVERLEAF LN
ISLANDIA NY 11749-1607
Pay to the
Order of ,
2728
1.32/210 NY
C� (� 29962
Date
I $G�����
�- Dol ar �•�•°° °°
Bank of America"!
ACH R/T 021000322 (on ^
It
Is I—. -
For
1:0210003 221: 009399238L2Sas2?28