77704D - Dobrzanski

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: PGIU/ '(/off 77rirtS/c!
Mailing Address: J l 9/$ //c 4d�(l
y J/ ^A 4,,75%ow,t-, M/l f)
Phone Number: 3oJ-Ii . O %a '
Email Address:
I certify that I have authorized nil.ejl '/v onrAel �i d-ialer ,
Agent/Contractor
to act on my behalf, for the purpose of applying for and obtaining,all CAMA permits
necessary for the following proposed development )C i R 1 k1e J
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' at my property located at /c)S .t/tlesr.f. l trr) lir • ,
.in • 1,7r/fi?S+/dL. 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 rwith `evaluating information related.to this , •
permit application- -,. ; 5. r, -'
Prope I • Infor ation: '
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This certification is valid through :./ I , ' I, .'°2,) ; i F r . ,

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ADJACENT RIPARIAN PROPERTY OWNER STATEMENT •
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I hereby certify that I own property adjacent to Pi al `)/'b• t.7-r%1)1"`� ,s
1 1 j (Name o Property Owner)
` property located at ) i/V�SF f°�'i 121
• (Address,Lot,Block,Rod,on DayiS etc.) .T. , N C
4 , in ©r1J - i
ate body (City/Town and/or County) -
t?r
t t The applicant has described to me, as shown below, the development proposed at the above
i''. locatio
' 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)
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d ;; 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'rfrom my area of riparian:access unless waived by•
' me.'(If you w•ish to waive the setback,you must initial the appropriate blankbelow:), ' '`;, .' ' t
"" ' '. I do wish to waive the 15'setback requirement ,'
xr ' I do not wish.to waive the 15'setback requirement,!,i ;,.
, , (Property'0 or 4 dcen Propert 0 Information) {`'
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Sigi'al zi ,, 7 :t F } p ' i`S 1,1,. .•1 r 1.t s 4CJLJ�%i�
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Print or Ty,eName .',;i .,v.:,.',`';j. or ype N';:
Mailing'A dress �,. 4.1/17, Ting Address " '
City/Statei� tl / C Staatte2 • ,
30i (D5 o2s • ,j. S' O /
•
Telephone Number/email address: ,, tTeleph a Nu"ber/email address Y,—..._;
Date
Date* r: ,:i.
' • % . , ,'(Revised Aug.2014) ,,. d.;.
*Valid for one calendar year after signature* �+ ;' r',.
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ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to /?JtLI tzqiick/ 's
property located at ),r /NSF r�/ fie of Property Owner)
ri
(Address,"Lot, Block,Rod,etc.)
on 1ayl5 (1�q , in i , N.C.
(Waterbody) (CityiTown and/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)
c &z/ke
Aac\ t) 61a1/1/1),-) /1)04, 199C. rflePikis
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.
/7- I do not wish to waive the 15'setback requirement.
(Property er for (A " ent P ope rty Owner Information)
Signatu Si tur * ,�//
jt7�� �.' 1 tms
Print or Type Name Print or Type Name
96/`0 frin id1) C/ 3 91 ? 1- .110e Dr
Mailing Address Mailing Address.
Ha -�;t urgt t /Z a)7 L'1�� w o � l
City/State/tV City/Slate/Zip
361 - yes-Oafs 76i1- 9°i -�6�1
Telephone Numbr/email address Telephone umbe /email address
i 161 R 1 13�a 1
Date Date*
(Revised Aug. 2014)
*Valid for one calendar year after signature*

Check
Date Received Date Deposited Check From(Name) Name of Permit Holder 1Mdur 11/ amount Permit Number/Comments Receipt or Refund/Reallocated
Coumnl Column2 Ceiumn3 Co/umnd_ Column8 Columns Column? Cdumn8 Column9
/25/2021:. 1126/2021 Elizabeth Edmunson -Robbie Edmunson State Employees CU 5021:$ _400.00 GP#77738D _ JD rct.13605
252021 1/26/2021 Holden Docks and Bulkheads Cathy Louden _CresCom Bank 3650i$_ 400.00 GP#77726D BB rd.13505 _
25/2021! 1/26/2021 Allied Marine Contractors LLC .Janet Friday FCB 9757,$ 200.00 GP#77737D ___ _ JD rot.13606
—-- — —..
252021_ 1/26/2021.Brandon Grimes Money Order Ban/and Seena Gudelskv Wells Fargo Bank 19-088347337 $_.-400.00 GP#77652D BB rd.13581 _
/25/2021 1/26/2021.Brandon Gnmes Money Order Kelly Coy Wells Fargo Bank 19-088347328 $ _ 400.00 GP#71880D BB rct.13579
252021 1/26/2021 CLTMC,Inc. Paul Watson FCB 1156.$ 800.00 GP#77538D _ _ _ Ben rct 12456 _
/25/2021_ 1262021 Allied Marine Contractors LLC Barry Sheppard .FCB 9737 $ 200.00 GP#74282D Tmac rct.13582 _
25/2021 1262021 Allied Marine Contractors LLC Paul Dobranski FCB 9738 $_ 600.00 GP#77704D Tmac rct.13583
J 25/2021 1/26/20211 Jerry Brinell David Moore Coastal Bank and Trust 3580 $ 200.00 GP#77527D JD rct.13608 __
/25/2021 1/26/2021 Rainwater Coastal Conslruction Herbert and Michelle Siner First Bank 358 $ 200.00 GP#71864D Tmac rct.13585
25/2021. 1/26/2021 Kevin Morse same BB&T 2696 $ 200.00:GP PArct.11579
._ _.
/25/2021 1/26/2021Overbeck Marine Const.IDaniel Shirley Carrie Fales Suntrust 5388 $ 400.00 GP#76172D _ PA rct.11580 _
/25/2021 1/26/2021 Phyllis Smith money order same BOKF.NA .20944262475 $ 200.00 GP#77590D EKE rct,13665 __
/25/2021 126/2021 Roger Davis Roger and Perry Davis BB&T 5446 $ 400.00 GP#76493D PA rct.11581