56523D - Otter

HCDEHR
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: < 2L c
Name of Property Owner Applying for Permit: Name of Authorized Agent for this project:
Owner's Mailing Address:
T Q tS," ��SS
Phone Number 610 ) 414; -
Agent's Mailing Address:
55712
Phone Number l W-h 4, p 7 — 7
I certify that I 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):
/�1, k d,C� t L
(my property located) at
This certification is valid thru (date) - - -
Property Owner Signature Date
127 Car&al Drive EA., Vftinglon, NC 284M NorthCarolina
Phone: [phone] FAX: [phone] Intmlet www.nccoar;WmansgemenL W Naturallb
An Ea al 0v=Wmty 1 Pyre Jcdon Empb)m

FROM : GOLDEN SANDS MOTEL PHONE NO. : 910 458 3093 Oct. 04
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PICR/MOORING pIL1NGS/BOATLI FT/BOA 17HOUSE)
I hereby certify that I own property adjacent toU(Name of Property Owne
—
property located at (Lot, Block Road, etc.)
' in --
On � t�/�L••��'eA('town and/or County)
(Waterbody)
He ha, described to me, as shown below. the development he is proposinga t t hat boathi ut
locatiol
no Objections to his proposal . I understand that a pier/mooring p gs
back a muumum distance of fifteen feet (15') from my area of riparian cess blank less al
(If you wish to waive the setback, you must initial the appropriate
I do not wish to waive
I do wish to waive that setback requirement. _---------- _---
-- - - - - — ---------------------- — --- --- -------------- —------ --- .
DESCRIPTION AND/OR DRAWING OF PROPOaSSFD DE'VELM
(To be frdkd in by individttal proposing )
- ---------- ---.-----
Owncr/A Hcant (Riparian Property woer
(Iaformationfor Property PP -
Applying for permit) c
Mailing Address
e
o

■ Complete items 1, 2, and 3. Also complete
item 4 it 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.
A Signature
13>�ent
X - ' ❑Addressee
B. Rec by ( / '
11 �V`'!.
C. Q?ts of N�y
D. 'is delivery address different from (tern 17 []Yes
If YES, enter delivery address below: ❑ No
1. Article Addressed to:
�� �✓' • 'S �.y��ti�re-
3. service Type
0-6egised Mail ❑ Repress Mail
p Registered ❑ Re1um Rec�pt for Merchandise
❑Insured Mal ❑ C.O.D.4.
ResMcted Delivery? (Extra Fee) ❑ Yes
2- Article Number 7009 3410 0001 5767 7357
(r mier d'om service label)
PS Form 3811, February 2004 Domestic Return Receipt 102595-02-M-IW
■ Complete items 1, 2, and 3. Also complete
A. SlgnaW j ✓'
Item 4 if Restricted Delivery is desired.
■ Print your name and address on the reverse
X �''''!% k ! ,' addressee
f.tar
so that we car return the card to you.
■Attach this card to the back of the mallpiece,or
R_ Reed by (Printed
on the front if space permits.
r. -` `�'
D. Is delivery address differerrtfrom
1. Article Addressed to:
if YES, enter delivery address below: 0No
Vr��7���.��'t-C�_-��SVyV �'-'u-�'t�
i �N11Y KAN, NC 29428
c—��
�b y G +-r�...�%. �� T>a
3, S rwca Type
11
lit-'Vl-� �, irA �C`•'4� V- C
cenAW Mal El Express Mall
❑ Registered ❑ Return Recelpt for Memhandise
,y ry/
❑ Insured Mail ❑ C.O.D.
4. Restricted Dell oery7 (Exha Fee) ❑ Yes
2. Article�N tuber 7009 3410 0001 5767 7463
PS Form 3811, February 2004 Domestic Return Receipt 02595-02 M.f540
■ Complete Items 1, 2, and 3. Also complete
A Signature
e
item 4 if Restricted Delivery 1s desired.
X ❑ Adc
■ Print your name and address on the reverse
so that we Can return the Gard to you.
■ Attach this card to the back of the mailpiece,
Received by (Printed Name)
C. Date of C
/8 , 5 r
or on the front it space permits.
D. Is delivery address different from item 17 ❑ Yes
1. Article Addressed to:
If YES, enter delivery address below: ❑ No
�a t wo n 3-cwu r'S
thus
'i�•i.Fly"t•�'tP�i of
rvl Type
O-Certified Mail ❑ Repress Mal
',. tA�tc,`� i'tl i� — Fj �Cq'\,•.( �`
❑ Registered ❑ Return Receipt for Merchandise
--•y
0 Insured Mail ❑ C.O.D.
4.
Restricted Dallveryfl (Exba F6e1 ❑ Yes
2. A•ticieNumber 7009 3410
0001 5638 7981
ritansfer from service 7ebeq
PS Form 3811, February 2004 Domestic Return
Receipt 102595-024*1540

MC Division of Coastal N19t. Habitat impact Computer Sheet
Applicant: �rr'e Y
Date: 1?I1!5111 1
Z' �� l �1�
�� Permit 2.3
Describe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
found in your Habitat code sheet.
DISTURB TYPE
Habitat Name Choose One
Fanticipated
TOTAL Sq. Ft.
(Applied for.
Disturbance total
includes any
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 fina
disturbance.
Excludes any
restoration andh
temp impact
amount
G 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 ❑
ge ❑ Fill ❑ Both ❑ Other ❑
:hDred�geE]Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both Cl Other ❑

EXIT PLAN LLC
4745 SILABERT AVE
CHARLOTTE, NC 28205 1001
67-98/532
Pay to the
Order of Date
Dollars 1�)
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