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AGENT AUTHORIZATION FOR LAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: 9,pr /l �,,,� le?r
Mailing Address: 15 it Ad,-k, Me,( MI 27
Phone Number:-%f��-.�f
Email Address:
I certify that I have authorized ��1`- ohs ,
Agent I Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: &,.t,?`- [ 2Lx- :: of d a-
Px
at my property located at 1 j if 0^ lri,n 411 14W-L e 2Ty�l
in U 1W7--v G County.
I furthermore certify that 1 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.
f
Signature
Print or Type Name
Title
Date
This certification is valid through 1 1,

DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
CERTIFIED MAIL • RETURN RECEIPT REQUESTED or HAND DELIVERED
Name of Property Owners
Address of Property: l f f Z c 4 h A01 c4".A
(Lot or Street #, Street or Road, City & County)
Agent's Name #: P?2r41 11,2; I Iv ,a,.'t � 42j, 4 d ) e,Mailing Address:
Agent's phone #:
CS S I." 1411'e f ?, vme
`Ct dev;fl H,
?7y4fy
I hereby certify that i own property adjacent to the above referenced property. The individual
applying for this permit has described to me as shown on the attached drawing the development
t ey arp proposing_ A jc nption or drawing, with dimensions, must be provided with this letter.
[ hay'e no bfections to this proposal- I have objections to this
proposal.
If you have objections to what is being proposed, you must notify the Division of Coastal .
Management (DCM) in writing within 10 days of receipt of this notice. Correspondence should be
mailed to 401 S. Grfffln St, Ste 300, Elizabeth City, NC, 27909. DCM representatives can also be
contacted at [phone]. No response is considered the same as no objection if you have been
noted by Certified Mail.
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 sign the appropriate blank below.)
(Property Owner Information)
J°{gna{ure
ii Print or Type Name
Mailing Address
1 do wish to waive the 15' setback requirement.
1 do not wish to waive the 15' setback requirement.
(A�anop Owner Information)
S gnature *
Q
Print or Type Name
4,42
Mailing Address

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UUNITED.STATES
MSTAL SERVICE.
KILL. DEVIL HILL
,i02 5 CRGAIAN HWY
K111. fIEVII H-RI-S NC 27948-9998
07,13/0)21 1800)275-8-777 12:32 PM
PI -OdLICI 0 tv U11i t Pr I oe
Price
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Fir=.t-Cia6s Mallet 1
$0. 55
L el ter
Kitt,, Hawk, NC 27949
Wei Ai it: 0 1 b 6. 70 oz
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Card Name: VISA
Ac-coun* #:
Approval N: 034261
Transaction #: 920
Receipi #: 019730
Debit Card P1.117""hiSe: $TGG
Ali). AC,:J00(-.9)0980840 t1i I p
AL: US OFBIl
PIN: Verified
U.S. Postal Service"
CERTIFIED MAV RECEIPT
Domestic Mail • ilxreasrs and limited enp] ovee
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Kittq H4wkj NC 27949
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PT UNITED STAT
ES
l�i�r►�TA sLRYicE.
KITTY HAWK
3841 N CROATAN HWY
KITTY HAWK, NC 27949-9238
[phone]
06/21/2021 10 03 AM
Product sty Unit Price
Price
__________-
First -Class Mail@ i$0.55
Letter
Kitty Hawk, NC 27949
Weight: 0 lb 0.70 oz
Estimated Delivery Date
Thu 06/24/2021
Certified Mail! $3.60
Tracking #:
70203160000125222344
Total $4.15
Grand Total: $4.15
Debit Card Remitted - - ----- - $4,15
Card Name: VISA
Account #: XXXXXXXXXXXX2904
Approval #: 095815
Transaction #: 298
Receipt #: 021037
Debit Card Purchase: $4.15
AID: A0000000980840 Chip
AL: US DEBIT
PIN: Verified
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
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xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
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UFN: 364144-0449
Receipt #: 840-52700344-3-4208258-2
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Currituck County GIS Data Viewer
Currituck County GIS
Phone: [phone]
E-mail: [e-mail]
Addresses
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AydkNt
Barco
Coinjock
Corot
Currituck
Gibbs Woods
Grandy
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Jarvisburg
Knott Island
Maple
Moyock
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Poplar Branch
Poweb Pont
Shawboro
Sligo
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County Boundary
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Wright Memorial Bridge
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— Arterlal_Pr»cipal
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Currituck County
Aerial Photography (2011
ERed: Band_1
EGreen: Band-2
Blue: Band_3
This map should be used for general reference purposes only. Currituck County assumes no legal liability for the information
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