77482_Aric DeHog Jr._20201125

/
4111 Lp1CAMA/ Eft/DREDGE & FILL S S No. 77482 A B ' C D
GENERAL PERMIT -ib-#(0�11O°� Previous permit#
)c= TINew El Modification El Complete Reissue ❑Partial Reissue Date previous permit issued .
As authorized by the State of North Carolina,Department of Environmental Quality and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC ) 7f/
/ . // v�� .
ij Mules attached.
Applicant Name i i f /JE( .:./ ,'i. Project Location: County , ;
Address `/I// !/., zi, ��,, L,.,e Street Address/State Road/Lot#(s) 1 V V J /
City I r /l., e.Pi- State 411( ZIP : = 7 ji O LC.,N �
Phone# (-2 ) il V�'- 9L'G,E-Mail Subdivision 1�c.- /.i /,,,-/- e;,,, .o
Authorized Agent ifL /2 r`,, // // // City h /X t v,, ZIP .��/ /10
Affected ❑CW ❑EW E PTA C9' S Phone# ( 2)V'c River Basin / ,/,e,
❑OEA ❑HHF ❑IH ❑UBA ❑N/A ,�
AEC(s): Adj.Wtr. Body / , ,:4 �. ,v - (nat /man /unkn)
❑ PWS: //9
ORW: yes /;no PNA yes / no Closest Maj.Wtr. Body
Type of Project/Activity A- / // //' �, I / ,
-` ,.J i/fu(H hz // ii, / i , . (Scale: )
Pier(dock)length
I ! I
Fixed Platform(s) �►
'/ �■Ia1• �� ■■�
Floating Platform(s) „ �
Finger pier(s) r,it ■ f
Groin length
number ) I ' ' ' -,-. ' : ! .
■ !
Bulkhead/Riprap length 4,0 2 ' • r -
avg distance offshore 0' ONE ■■
max distance offshore Q' � II_ IIII11IIIIH
Basin,channelMIMI
MM.
cubicyards ■ ill11�' .-_._ ■ ■■
■■ 1 ■■■■ ■ 1,,,..111, ,, ,
Boat ramp
1 Boathouse/Boatlift
Beach Bulldozing 1!ui -- +
' Other /.r 44�. / ram,.-, j ' • I _ . '
.f r
T .
' ipilli 1 ,
Shoreline Length // I ■■ _._..__ J / / ; Q —_ t �r 111
'..._....
SAV. not sure yes n ( f
/�� f ■
Moratorium: n/a yes (y {,
.� i 1cr S r 1-.... t
Photos: yes
Waiver Attached: yes no I / / e't 4 ') , i I
A building permit may be required by: J:°e,, ' [ e . See note on back regarding River Basin rules.
(Note Local Planning Jurisdiction) �
Notes/Special Conditions ,-« 67!/ //17U _, t- h r y>rf (r// i_r -r// / ,-r e / /-1-'1-9
fiv/a CCtC, 1r �J e"e i� •✓ r J/
/
t P Aame Permit Officer's Printed Name
-- .
(6(4
Signature 'Ple ' read compliance statement on back of permit** Signature
/ jv-- . ... ,26-2 0 V/ / . moo, /
Application Fee(s) Check# Issuing Date Expiration Date

Statement of Compliance and Consistency
This permit is subject to compliance with this application, site drawing and attached general and specific conditions. Any
violation of these terms may subject the permittee to a fine or criminal or civil action; and may cause the permit to become
null and void.
This permit must be on the project site and accessible to the permit officer when the project is inspected for compliance. The
applicant certifies by signing this permit that I)prior to undertaking any activities authorized by this permit,the applicant will
confer with appropriate local authorities to confirm that this project is consistent with the local land use plan and all local
ordinances, and 2) a written statement or certified mail return receipt has been obtained from the adjacent riparian
landowner(s).
The State of North Carolina and the Division of Coastal Management, in issuing this permit under the best available
information and belief,certify that this project is consistent with the North Carolina Coastal Management Program.
River Basin Rules Applicable To Your Project:
Tar-Pamlico River Basin Buffer Rules Other:
Neuse River Basin Buffer Rules
If indicated on front of permit,your project is subject to the Environmental Management Commission's Buffer Rules for the
River Basin checked above due to its location within that River Basin. These buffer rules are enforced by the NC Division of
Water Resources. Contact the Division of Water Resources at the Washington Regional Office (252-946-648 I) or the
Wilmington Regional Office(910-796-7215)for more information on how to comply with these buffer rules.
Division of Coastal Management Offices
Morehead City Headquarters Washington District
400 Commerce Ave 943 Washington Square Mall
Morehead City, NC 28557 Washington, NC 27889
252-808-2808/ I-888-4RCOAST 252-946-6481
Fax: [phone] Fax: [phone]
(Serves:Carteret,Craven,Onslow- (Serves: Beaufort, Bertie, Hertford, Hyde,
North of New River Inlet-and Pamlico Tyrrell and Washington Counties)
Counties)
Elizabeth City District Wilmington District
40I S. Griffin St. 127 Cardinal Drive Ext.
Ste. 300 Wilmington, NC 28405-3845
Elizabeth City, NC 27909 910-796-7215
252-264-3901 Fax: [phone]
Fax: [phone] (Serves: Brunswick, New Hanover,
(Serves:Camden,Chowan,Currituck, Onslow-South of New River Inlet-
Dare,Gates, Pasquotank and Perquimans and Pender Counties)
Counties)
http://portal.ncdenr.org/web/cm/dcm-home
Revised 7/06/17

- , Y
411111 LAMA/ ©DREDGE & FILL =0 it _7 C NO 77482 A BCD
GENERAL PERMIT ( Previous permit#
> = ❑New ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
As authorized by the State of North Carolina,Department of Environmental Quality
and the Coastal Resources Commission in an area of environmental concern pursuant to I 5A NCAC
Rules attached.
Applicant Name i ' . Project Location: County
Address , , I / . .l ,' Street Address/State Road/Lot#(s) '! /,, /
City State ZIP
Phone#( ) E-Mail --•--- Subdivision
Authorized Agent / City ZIP ,
1-1 CW ❑EW ❑PTA ❑ES 'ElPTS Phone# ( ) River Basin
Affected ,OEA ❑HHF IH UBA III N/A
AEC(s): Adj.Wtr. Body (nat /man /unkn)
❑ PWS:
ORW: yes / no PNA yes / no Closest Maj.Wtr. Body
Type of Project/Activity
(Scale:, )
Pier(dock)length
I
Fixed Platform(s) >' i
Floating Platform(s) r/ µ , , 7
Finger pier(s) �.�
— ---jam- .. I _ —I —�.__...
Groin length ' i {
number - _.. i 1-- ...... j .,_ _._...._ -, - ..i.........
Bulkhead/Riprap length ,/,,;, 4 ...._ I — — i.. ,..
+ 1-- I -� `
avg distance offshore ram% I
max distance offshore t; I L __ _ _ l _y : - i
Basin,channel _ 4 '
{` il i 1 j
cubic yards , , 7 \s,,* ,
III '
Boat ramp ' : ( r / . / r �r
... I 1:`Boathouse/Boatlift ` — I. _ j .._ �...
1 t '
r....... —a —' = i r -- 7
Beach Bulldozing — T_ (.._) _ ' ' i j —_.-I . ,
Other_ 1 j{: ��j • 1
Shoreline Length //l✓' c I I j
Al l t l 1 1 -` vy
SAV: not sure yes �n /'o ft. -r+t,+ j T- '_ _.-I._..1 I i c i I/'1 ;;1'11•
E -I ___
Moratorium: n/a yes no � — —'
1 ' l r-r f) Al
Photos: yes no
I • t , ! k
I r _
Waiver Attached: yes no r' j
A building permit may be required by: . [ 'See note on back regarding River Basin rules.
(Note Local Planning Jurisdiction)
Notes/Special Conditions
Agent or Applicant Printed Name Permit Officer's Printed Name
Signature **Please read compliance statement on back of permit** Signature
G /
Application Fee(s) Check# Issuing Date Expiration Date

Statement of Compliance and Consistency
This permit is subject to compliance with this application, site drawing and attached general and specific conditions. Any
violation of these terms may subject the permittee to a fine or criminal or civil action;and may cause the permit to become
null and void.
This permit must be on the project site and accessible to the permit officer when the project is inspected for compliance. The
applicant certifies by signing this permit that I)prior to undertaking any activities authorized by this permit,the applicant will
confer with appropriate local authorities to confirm that this project is consistent with the local land use plan and all local
ordinances, and 2) a written statement or certified mail return receipt has been obtained from the adjacent riparian
landowner(s).
The State of North Carolina and the Division of Coastal Management, in issuing this permit under the best available
information and belief,certify that this project is consistent with the North Carolina Coastal Management Program.
River Basin Rules Applicable To Your Project:
Tar-Pamlico River Basin Buffer Rules Other:
Neuse River Basin Buffer Rules
If indicated on front of permit,your project is subject to the Environmental Management Commission's Buffer Rules for the
River Basin checked above due to its location within that River Basin. These buffer rules are enforced by the NC Division of
Water Resources. Contact the Division of Water Resources at the Washington Regional Office (252-946-6481) or the
Wilmington Regional Office(9 I 0-796-72 1 5)for more information on how to comply with these buffer rules.
Division of Coastal Management Offices
Morehead City Headquarters Washington District
400 Commerce Ave 943 Washington Square Mall
Morehead City, NC 28557 Washington, NC 27889
252-808-2808/ I-888-4RCOAST 252-946-648 I
Fax: [phone] Fax: [phone]
(Serves:Carteret,Craven,Onslow- (Serves: Beaufort, Bertie,Hertford, Hyde,
North of New River Inlet-and Pamlico Tyrrell and Washington Counties)
Counties)
Elizabeth City District Wilmington District
401 S. Griffin St. 127 Cardinal Drive Ext.
Ste. 300 Wilmington, NC 28405-3845
Elizabeth City, NC 27909 910-796-7215
252-264-3901 Fax: [phone]
Fax: [phone] (Serves: Brunswick, New Hanover,
(Serves:Camden,Chowan,Currituck, Onslow-South of New River Inlet-
Dare,Gates, Pasquotank and Perquimans and Pender Counties)
Counties)
http://portal.ncdenr.org/web/cm/dcm-home
Revised 7/06/17

ROY COOPER
,•"' Governor
MICHAEL S. REGAN
Secretary
Coastal Management BRAXTON DAVIS
ENVIRONMENTAL QUALITY Director
BUFFER AUTHORIZATION CERTIFICATE FOR SHORELINE STABILIZATION
A riparian buffer authorization is required for shoreline stabilization activities within the Neuse and Tar-Pamlico River
basins per Division of Water Resources(DWR) regulations 15A NCAC 02B.0233 and 0259. The Division of Coastal
Management(DCM)through a Memorandum of Understanding with the Division of Water Resources(DWR) has
reviewed your project proposal and has determined that the project as proposed complies with the aforementioned
regulations.
Those activities covered by your Coastal Area Management Act(CAMA) permit have received Buffer Authorization
provided the project is constructed in a manner that continues to meet all of the conditions listed below.Failure to
comply with this Buffer Authorization may subject the property owner and the party(contractor) performing the
construction and/or land clearing to a civil penalty by DWR of up to$25,000 per day per violation.
i. Impacts: Impacts to woody vegetation from clearing and filling in Zone 1(begins at the most landward of either
normal water line(NWL)or normal high water line(NHWL)and extends 30 feet landward)shall be minimized to
what must be impacted for the sound installation of the shoreline stabilization project. Unnecessary clearing and
filling in the buffer is a violation of the riparian buffer rules.
2. Clearing& Grading:Clearing and grading of Zone 2 (begins at the landward edge of Zone 1 and extends 20 feet
landward) is allowed provided that it is re-vegetated immediately and Zone 1 is not compromised,which includes
maintaining diffused (non-channelized)flow of storm water runoff through the buffer.
3. Construction Corridors:Construction corridors are allowed for shoreline stabilization projects, but they must be
satisfactorily restored as described in condition 5 below.
4. Potential Overwash: For vertical shoreline stabilization projects (bulkheads)only;sites where wave overwash is
expected to be severe,the first ten(10)feet landward(unless specifically authorized otherwise by DCM)from the
structure may be maintained as a stable lawn in order to provide for structural stability.
s. Temporary Stabilization: Immediately post-construction, bare soils must be stabilized as quickly as possible by
providing a temporary ground cover. Newly seeded areas should be protected with mulch and/or erosion matting.
This ground cover is a temporary measure used to address erosion until site restoration can be accomplished.
6. Site Restoration:At minimum,pre-project site conditions must be re-established.A site that was wooded prior to
this shoreline stabilization project must be restored with woody vegetation at a stem density of 260 stems per acre.
Non wooded sites may be re-vegetated with woody vegetation. Restoration must be completed by the first
subsequent planting season (November 1 through March 30) after completion of the bulkhead.
• Pre-project site conditions:
7. Project Drawing:The drawing on the CAMA General Permit is considered the project drawing of your property
indicating the location of the shoreline stabilization structure and anyassociated clearing,
grading,and construction
corridors.This drawing will be used to aid in compliance and monitoring efforts.
By your signature below you agree to be held responsible for meeting all of the above lis#ed onditions and verify that all
informs '• is c• plet an accurate.
Age v%Appl- - P " ted Name eP' rmit icee '5ighature
Agent or Applicant Signature Issue Date
CAMA GENERAL PERMIT#: l g2 17
State of North Carolina I Environmental Quaitty I Coastal Management
Washington Office 1943 Washington Square Mall Washington,NC 27889 1252-946-6481
Wilmington Office 1127 Carrfinal flrive Evt VVln,ingtnn NC 78405_3845 i 91n_79%_72I5
Morehead City Office 1400 Commerce Avenue Morehead City.NC 28557 1252-808-2808

vYd� r� w
ROY COOPER NORTH CAROLINA
Governor Environmental Quality
MICHAEL S.REGAN
Secretary
BRAXTON C.DAVIS
Director
November 30, 2020
Bob Carlyle
A-Wall
18 Water Street
Aurora, NC 27806
Attached is General Permit#77482-B and Buffer authorization form.To validate this permit,please
sign the permit in the bottom left hand corner below your already printed name,as indicated.
Retain the white copy for your files and return the signed yellow and pink copies to us in the
enclosed,self-addressed stamped envelope. If the signed permit copies are not returned to this
office before the initiation of development,you will be working without authorization and will be
subject to a Notice of Violation and subsequent civil penalties.
If you have any questions regarding this correspondence,please don't hesitate to call our office at
the number below.
Thank you,we appreciate your attention to this matter.
Sincerely,
K ri Sparks
Administrative Support
Division of Coastal Management
943 Washington Sq. Mall
Washington NC 27889
[phone]
1 -D_EQ,)
North Carolina Department of Environmental Quality I Division of Coastal Management
Washington Office 1943 Washington Square Mall I Washington,North Carolina 27889
252.946.6481

0 1-CAMA / 1 DREDGE & FILL A 111, C D
GENERAL PERMIT Previous permit#
> New JModification JComplete Reissue E Partial Reissue Date previous permit issued -a/
As authorized by the State of North Carolina,Department of Environmental Quality ��� �`
and the Coastal Resources Commission in an area of environmental concern pursuant to I 5A NCAC /"
L� // J es attached.
Applicant Name !���� del ov Ji, Project Location: County / 14ds f
Address V V u:.-1 t i / L<-,.i€ Street Address/State Road/Lot#(s) yy( v.-i1'/;c I
City XI/4.-ee. State/I/6 ZIP �T,e/Q 2zn� Q
Phone#(� 9 'Y-- % 6 fE-Mail — Subdivision i t,dJ// 14 / /
`,Authorized Agent b ,, / i. City le'A,CKk ZIP 2 7F/a
J Affected CW ❑EW CI PTA fl'PTS Phone# ( Stir,� River Basin / -/�,^
❑OEA ❑HHF ❑IH ❑UBA ❑N/A / /
AEC(s): Adj.Wtr. Body c-t /vt.,--
-' PWS: � an unkn
ORW: yes / no PNA yes / no Closest Maj.Wtr. Body "1 n� /l lees
Type of Project/Activity reef ee_ //3 ' e, T 6 �4_ 1 4<< c' ,.., Se C0 C. %SS. ,v., i.2-1-,,a ei '/a f
r' "ct, tint /5 ' ,.ta,., w</!� t4c7 7v &1/ L./ /
Pier(dock)length si (Scale: / '`- 761"„ )
Fixed Platform(s) _ _ '7 • - ` _-- - -
Floating Platform(s) ,
Finger pier(s) , • i
Groin length J + i i
number _
Bulkhead/Riprap length J/Q f -? -1- --�--t..... .T- . r.. J. - -
avg distance offshore 0 ;
ir
J—I
max distance offshore Q'
Basin,channel - • __ - {
cubic yards
r • • - } Ti--4- — -- - - rV�
Boat ramp , - : _ ,7
Boathouse/Boatlift 1 !- �.- - = - —:_ _ ...._ : _...._ ! I i,.. " I T '�
I I
I
Beach Bulldozing ' i r'
Other /� ' �itr�r�O
/wfarN w=/
c:4 C. cam.) v aa0U1Iv . — --
_.- E ._- ijr
Shoreline Length // 1171 i"C f7 f��c ~
SAV: not sure yes C) - •rtMi ,b4 47 r -
•
Moratorium: n/a yes CP ..t� .,...-r - . vpit•A-i1,+ - - -
{
Photos: yes n
Waiver Attached: yes no 7• _--___ I -
A building permit may be required by: «.0 -91 6. . ' See note on back regarding River Basin rules.
(Note Local Planning Jurisdiction) // J
Notes/Special Conditions t'ae 0 7/ / a ,b,-• /i 7'n), f I re ,.../ J ,..1.6.,./c.: ..e i' ./4...•74
5010 Car1. le. ,_57,_ f.,4 r �� //
Agent or Applicant P inted Name Permit Officer's Printed Name
�� t
Signature **Please read compliance statement on back of permit** Signature
-,> '''� j7 zI 4 c'v .25 2 0..2-0 /1i 4 4 ,25 2'M
Application Fee(s) Check# Issuing Date Expiration Date
IL

ROY COOPER
�•? Governor
MICHAEL S. REGAN
Secretary
Coastal Management BRAXTON DAVIS
ENVIRONMENTAL QUALITY Director
BUFFER AUTHORIZATION CERTIFICATE FOR SHORELINE STABILIZATION
A riparian buffer authorization is required for shoreline stabilization activities within the Neuse and Tar-Pamlico River
basins per Division of Water Resources(DWR) regulations 15A NCAC 02B.0233 and 0259. The Division of Coastal
Management(DCM)through a Memorandum of Understanding with the Division of Water Resources(DWR) has
reviewed your project proposal and has determined that the project as proposed complies with the aforementioned
regulations.
Those activities covered by your Coastal Area Management Act(CAMA) permit have received Buffer Authorization
provided the project is constructed in a manner that continues to meet all of the conditions listed below. Failure to
comply with this Buffer,Authorization may subject the property owner and the party(contractor) performing the
construction and/or land clearing to a civil penalty by DWR of up to$25,000 per day per violation.
>. Impacts: Impacts to woody vegetation from clearing and filling in Zone 1 (begins at the most landward of either
normal water line(NWL) or normal high water line(NHWL)and extends 30 feet landward)shall be minimized to
what must be impacted for the sound installation of the shoreline stabilization project. Unnecessary clearing and
filling in the buffer is a violation of the riparian buffer rules.
2. Clearing& Grading:Clearing and grading of Zone 2 (begins at the landward edge of Zone 1 and extends 20 feet
landward) is allowed provided that it is re-vegetated immediately and Zone 1 is not compromised,which includes
maintaining diffused (non-channelized)flow of storm water runoff through the buffer.
3. Construction Corridors:Construction corridors are allowed for shoreline stabilization projects, but they must be
satisfactorily restored as described in condition 5 below.
4. Potential Overwash: For vertical shoreline stabilization projects (bulkheads)only;sites where wave overwash is
expected to be severe, the first ten (10)feet landward (unless specifically authorized otherwise by DCM) from the
structure may be maintained as a stable lawn in order to provide for structural stability. •
s. Temporary Stabilization: Immediately post-construction, bare soils must be stabilized as quickly as possible by
providing a temporary ground cover. Newly seeded areas should be protected with mulch and/or erosion matting.
This ground cover is a temporary measure used to address erosion until site restoration can be accomplished.
6. Site Restoration:At minimum,pre-project site conditions must be re-established.A site that was wooded prior to
this shoreline stabilization project must be restored with woody vegetation at a stem density of 260 stems per acre.
Non wooded sites may be re-vegetated with woody vegetation. Restoration must be completed by the first
subsequent planting season (November 1 through March 30) after completion of the bulkhead.
a Pre-project site conditions:
7 Project Drawing:The drawing on the CAMA General Permit is considered the project drawing of your property
indicating the location of the shoreline stabilization structure and anyassociated clearing,g, grading,and construction
corridors.This drawing will be used to aid in compliance and monitoring efforts.
By your signature below you agree to be held responsible for meeting all of the above listed onditions and verfy that all
information is complete and accurate. = / / {
i I
Agent or Applicant Printed Name 1p'errn' t\Office�' 'Sighat re
/Z72 f/z
Agent or Applicant Signature Issu Date
CA►NIA GENERAL PERMIT#: 7 2 l KA
State of North Carolina I Environmental Quality I Coastal Management
Washington Office 1943 Washington Square Mall Washington.NC 27889 i 252-946-6481
Wilmington Office 1177 Carriinal OOrive E.t blfilmington NC 73405_384 5.i O10_796-7215
Morehead City Office 1400 Commerce Avenue Morehead City.NC 28557 1252-808-2808

ADJACENT RIPARIAN PROPERTY OWNER STATEME T
I hereby certify that I own property adjacent to �/� =-Xif s
-' Nafne of opener)
property located at -Y7L-� lZ��Cx, �:_ r
(Address, Lot, Blo k R• : c.)
on , in P , N.C.
(Wa��ody) (City/Town aid/or County)
The applicant has described to me, as shown below, the development proposed at the above
location.
-�� I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or groin
must be set back a minimum distance of 15' from my area of riparian access unless waived by
me. (If you wish to waive the setback, you must initial the appropriate blank below.)
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Pro y Owner Information) (Adjacent Property Owner Information)
ig ture se) �/P �GI-f
Signa 0 IC .�j2
Print or Ty Name �- Print or Type Name
62pg dpr te. Ma 7i g Address
uidetel:
pL
ity/State/Zip Aft /n City/State/Zi
Telephone Number/email address TeI ph ne Num r qddress
/2/0 -• aPY 0.2 51 .WQ cZe)
Date Date
(Revised Aug. 2014)
`Valid for one calendar year after signature*

224

ADJACENT RIPARIAN PROPERTY OWNER STAT ENT
I hereby certify that I own property adjacent to `:—ta/e , if. 's
417 eofPra Owner)
property located at ? wiv . S 2,'1-.�_
(Address, Lot,nOge9 Block, Ro , etc.) �/on , in �l''/RI,
1 ' (: , N.C.
(NJ�aterbody) (City/Town a�/or County)
The applicant has described to me, as shown below, the development proposed at the above
location.
�y I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or groin
must be set back a minimum distance of 15' from my area of riparian access unless waived by
me. (If you wish to waive the setback, you must initial the appropriate blank below.)
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Probity Owner In o mation (Adjacent Prope . Owner Information)
JJ
(w/j.i__ ! -/ ';:77-)/P2 --- ',2),AiY7 '
Signature*
d..../e ,://c....7_c_IT'.
1 Pri r Tye Name Print or Type Name ce.7. --
:e.Z7 ‘./ 1 ./), 1/ „er-7; P-? --57iF/%19'44.--
Made Addr , M ling Address 7
ity tate/Zip c"? "--02 —9 '-- -yei, ity/Sta i�n -
7 --- w
Telephone Number/email add ss Telephone Number/ema l address
4/a& a' e) >12. &
Date Date* /
(Revised Aug. 2014)
*Valid for one calendar year after signature*

a2ez } 17 ‘