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`�� AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: - 1.,z1704
Mailing Address: 73G�O � 7��7�`� /-1 , d7e'
e-/ 7 /3
Phone Number: 9I7 7,4 r/3-5°
Email Address: 77v/=17Xm3 cacrxk,
I certify that I have authorized (Lc- Ci..0)25/)4-c-c 4a-71
Agent/Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessaryfor the following
proposed development:
at myproperty located /� ,t't . �p p y at I 1 L�"N � � 1AV��,ivc_ftzA , /k.,
in Ai-.�i %4 County.
I furthermore certify that I am authorized to grant, and do in fact grant permission to
Division of Coastal Management staff, the Local Permit Officer and their agents to enter
on the aforementioned lands in connection with evaluating information related to this
permit application'.
Property Owner Information:
A J�
Signature
trNi A53-
Print or Type Name
Title
� f /O /_Aa�o
Date
This certification is valid through

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Lis ///617 .
AMA/ El DREDGE & FILL - \AS ND 77689 A B C W
GENERAL PERMIT Previous permit#
New ' -Modification ❑Complete Reissue Eli Partial Reissue Date previous permit issued
As authorized by the State of North Carolina,Department of Environmental Quality //��'J
and the Coastal Resources Commission in an area of environmental concern pursuant to I 5A NCAC U + k QU U .
iltI
❑Rules attached.
Applicant Name1 �'�^� Li U " 5 Project Location: County {�..s.....i c
Address ' /G'.Q ,,.A-r..„ti it, I L �,... Street Address/State Road/Lot#(s) ('(5
City i rY V t State NC, ZIP 2 ('3 Ca A \ t)r -
Phone# (y14 ) 14/ 103Y E-Mail . fL .4Nc,,, S 22Qr...a,I,co.Subdivision
Authorized Agent (n1C-,-- L.. C, %LA-- / City .14 f uk a.e•4 h ZIP 2 r``to)f
Affected ❑CW i'EW 014PTA ❑ES ❑PTS Phone# ( ) _ River Basin (. �•-
s OEA ❑HHF ❑IH ❑UBA DI WA
AEC : Adj.Wtr. Bod❑ PWS. y e G dom an /unkn)
ORW: yes /in,, PNA y n� Closest Maj.Wtr. Body At w V./
Type of Project/Activity _ f),,,\ c ,(c- A : }zc k'k 1-0� 1-e�. �� c,..... �. •Vim"
�... ..,,...,,.,. c S Ce s h.„ (Scale: /J T S )
Pier(dock)length LJ y(!`/ ' __
•
Fixed Platform(s) 1 2.1,1'Z' b'111,112111121111 A — •�
Floating Platform(s) Id, k Ala._ �\.
. i
Finger pier(s) ! '
Groin length i
number ; � l —__....—.......... -- —_--
Bulkhead/Riprap length i — ti
avg distance offshore r.. \ ', \
max distance offshore -I, OA i , 11 . i i 1
Basin,channel I- I fi -_
i I I I
cubic yards I I �ty
Boat ramp I I Boathouse/Boatlift — }
r—
Beach Bulldozing 1 ' -
�-- - '' " , rho
Other i
l
ik iI 1
Shoreline Length SO I , 1I `r. ,,^ ,,C : i
SAV: not sure yes no
Moratorium: n/a yes \ 4I j I }.... ^,,L — -
���,11,,nnnn �
Photos: _ , '
yes ; ,
Waiver Attached: yes CPI { ; t j '
A building permit may be required by: Sv r-k`4 (Sr if,C k . I See note on back regarding River Basin rules.
(Note Local Planning Jurisdiction)
Notes/Special Conditions `� ,J6,c(c,--.\ } . c , (,4 ( � L,,\`\ �._ t).J, f . S --�, c��i _C\
u- PAAd 1 1ffy,Gcc eocIA--
Agent or Applicant Printed Name PermitOffic ' nnted e
\ ..... (..t--,
Signature Please read col •liance statement on back of permit Signature
t. /P , IA_ '_(l . I t4 ( d 24 Zo2U 311(2o2(
Application .S s) Check# Issuing Date Expt�loon Date