56569D - Paliquras

-i "I
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
,veriy Eaves Perdue James H. Gregson Des r
3vernor 'Director Secretacretar
AGENT AUTHORIZATION FORM
Date: A.
[me of Property Owner Applying for Permit: Name of Authorized Agent for is protect:
uner's Mailing Address:
Agent's Mailing Address:
/ c
none Number ) Phone Number
certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
)r and obtaining all CAMA Permits necessary to install or construct the following (activity):
I) ir..""), ?, ,/ a i1" ,I(, I
my property located) at
rhis certification is valid thru (date)
ni a, -_ 7 1//�
LLAW1,(
___.__—
Property Owner Signature Date

� _ ._1.�. _" , .. 1. '(L. \Yl..;i �� I1 j\ r �Ji\.iV.
f Y1'_I--
Narre of ,.;div'&jal Applying
Address of f'repert 'c) � r- s
(Lot or Street, Street or Road)
(City and County)
I hereby certify that I own proper adjacent to the above -referenced properiv. The indivi
appi; ins for c::s permit has described Lo rnt� as sho�L'n on the attached drawing the development
are ;--opo:ing A descrioT' n or dmwir r, dimensions, should be provided «ithis iette
_ I have no objections to this proposal.
If you have objections to what is being proposed, please write the Division of Co&,
Management, 12" Cardinal Drive Extension, Wilmington, NC 28405 or call 910-796
within 10 days of receipt of this notice. No response is considered the same as no objectil
you have been notified by Certified Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boat house or boat lift must b
bck a minimum distance of 15' from my area of riparian access - unless waived by me. (11
w is give the setback, you must initial the ap�ropriate�blank below.)
T do wish IO waive :he 15' setback requirement.
l don t %..5h u: wal e the 13' setback requirement.
r._! -- %.r
AIF;.wvwA

t l.•1�'..sV`�lt,��^������.`?C�,_II�T'��.�„�'I,,,,,i���1.....��W4t \.: ( 1�,i qq+l.��t�l� �•..��rwl\ FOR.
Nine �f ?;aciividual ,kppl�'ir g 7 o, ?errtait IliF�.�?� fa ;,
Address of Proper,tiV�o 5 r � �Q� �� ; -IL
(:rot or Street , Stree> or lkoad)
L"-', (,-1 -
(City and (".ounty)
I hereby ce't'.fy tnat i own pro;c ty adjacc t ►o thy: aLave,referenced property, ane indiv
applying for this permit !►as described W Me as shoum." a.: the attacized drawing tl' e dVeiOpmen
are proposine. A dtSCripftl 07 tvit.h. ci ^aznsiens; should be provided with this Teti
I have no ;abjections to this proposal.
If you have objections to what is being proposed, please write the Division of Cc
Managtmint, 127 Cardinal Drive ,Extension, Wilmington, NC 28405 or call 910-0746-
within Io clays of receipt of this notiM No responsc is considered the same as no abject
you have tern notified by Certitled Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boat house or boat lift must
bcl: a minimum distance of 15' from nay area of riparian access - unless waived by me.'
wish to waive the setback, you must initlgi the appropriate blank below.;
5ign Nam
V< <r l�� ter✓
I da wish to %naive the 15' Se"back requirenit:M
I in,not lsr. to waive ',he i 5 setback requir::mcrt.
40 ��1D
�. mate

� � ` , ' � • ' 1�. � 'V'.....r� ��1�� � 1 ���1�. ��,�y • � i 1 � l • YY � � �J 31.�t i'7
Namt of n(lividual Apply'% = 0�
Address of
(Lot or Strdei #, Street ur Read j
(C ity and C c a ►tr }
I hereby ce't ' that I ov'n prar�My adjacent to .hw kbove-referenced propert;1. i'he indivi;
..l+ed co me as sho�xa Un the attached draw;'rVbC deve:apmen='
apFl}•ing for this pe:*nit �>a. des�ri
, «'ith dimensions, should be provided with this Ilene'
are proposing, A description or c'.a�vir;
I rave ro objections to this rraposal.
If you ha�,e objections to what is being proposed, please write the Division of Cot
Manacernimt, 127 �;ardinai Drive Extension, Wilmington. N'C 28405 or call 910-79t�-"
within 10 clays of receipt of this notice, No response is considered tie sama as no abjecti
you have been notified by Certified Mail.
WAIVER SECTION
I understand that a pier, dock:, mooring pilings, breakwater, boat pause cr `saat lift must I
bek a minimum distance of 15' from my area of riparian access - unless vs,aived by me. (I
wi,Rh to tiv- ive the setback, you must initiul the appropriate hunk below.)
I do wish to \naive the l' se,�_ack retluireir;enz
\/ ; cs �� ish. to ti� a;ve +y.e ': setback rec�,u►rerrcnt.
S' gn . ur.
Date
���� V_ ._.. -- _ MBA

SIC
-reated 10)01106
I
P&, 4w-
At
,tp://wwwdefault.nhcgov.com/servlet/com.esri.esrimap.Esrimap?ServiceName=advmap... 10/16/2006

Division of Coastal N19t. Habitat Impact Computer Sleet
)6cant: 14e le-kiI Pa l iPMM S Permit
Scribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
nd 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/or
temp impact
amount
Dredge ❑ Fill ❑ Both ❑ Other
12 U
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 ❑

COASTAL MARINE PIERS & BULKHEADS LLC
NCL 6314 W WLMNGTONANC 28403 VE 6-6357
TO THE
ORDER OF
17383
66-21/530
BRANCH 50004
DATE
.�
rr
WACUOVIA
Wachovia Bank, N.A. %� p
wechovia.com 7.-, C f C C_ t. �11 5o
R o.IID L91: 2086 L70 20896 L"• __
F• 0 5 3000 2