79731_L. Paige Davis_20210907

• CAMA/ DREDGE & FHL -- ;A J�� ^ 737 ' A ® C D
GENERAL' .PERMIT Previous permit# i..k/A
)� g ew. ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued iJ rfi
As authorized by the,State.of North Carolina,Department of Environmental Quality
and the Coastal'Resd irces Commission in an area of environmental concern pursuant to 15A NCAC 01�• MO (')'.i4.• 1 2©71
--_ ®Rules attached.
Applicant Name L• FrAlo,e Dow,J} Project Location: County ect q'b r4
Address ,f D at, ,ec RvP Street Address/State Road/Lot#(s)
City k,0tx5V‘i't'1�6+Ik'f� ' StateNt ZIP t.1- I9 /OS '��0r.-,-.\,N (.s� A j
Phone#(25 `f(4' "39(o2E-Mail -- -- ' Subdivision F- )1Pr
-� Q
Authorized Agent t(,Ky 01A5 City 1,4 `ON�t'7Et�fr b� -
'ZIP -7"SS 1
Affected ❑CW .KEW %1,PTA ZEE [��PTS Phone# (ZSZ)9(4.5 `
-
� /tc7- River Basin
❑OEA ❑.HHF ❑IH ❑UBA ❑N/A '��{,�,�,P r i
AEC(s): Adj.Wtr. Body 1 1) (a 2ti ve". iki-7 man /unkn)
ORW: yes❑/ noS "'PNA yes / Closest Maj.Wtr. Body Pa'Y \i ce (2'�'x'-'f
Type of Project/Activity `i!? 4 , "'I MO' eat~ pl ,A) b.4,k 'ecs) OR" A!tA;;d® r,. r t (. -rArn e 714 c't '.
,ffO(cQ rd/)M (P h ;�011/ C X/Se,' Fie/ cY I r CO` -.; .- i1'/ c oc -ev P) (Scale: it1- 3ca° )
Pier(dock)length /to el'r;/91° o ' •, ) ,C'r . �,..
II 't 2 o` `.it,q. Y'' • • '
Fixed Platform(s) ,,, ;;�� I ' �,ti„+l'r
Floating Platform(s) I ; . i ■� ��� 1 ' ; ,._;
Finger pier(s)
Groin length
, to , 7! i
gt
' number —' I I / ).e, . pi, ', — {•`? ... 1 —
Bulkhead/Riprap length j��' 1— _ � u_�'o_d e ' ,M —_{ � —
r ,
avg distance offshore 0• ,` k^ '�,r.\• f G' —O
max distance offshore Z. INII��. n- 1 _ • ` ,IIIIIIIIIIIIIIIIIIIIMIIIIIIIIIIIFIII _�
Basin,channel rP ��
- ' , cubic yards 1 1 Ell 111E11111BiallillIMMIIIIIIIII
Boat ramp I
( . i
Boathouse/Boatlift ! ' - -- --- -r- '•— �..0 : --I
1 f T 1
Beach Bulldozing i — �� �_ X ` — ; ;.l,r'—•`� ;f
6 4
Other i I � �® I ��
Shoreline Length , "/0 i ��
1.''' ,
Hgi
SAY: not sure yes no --, -- ;,�- ` — �
Moratorium: n/a yes no —�ilr ti e„ (Xy 7n —•LL b--
Photos: yes ?' '�Z ! c-C' 4� '' ,-, h; f-^ __... y
,,�p 1 ait, rat
Waiver Attached: es lb �ka
A building permit may be required by: (il Pf'riv (- • n See note on back regarding River Basin rules.
(Note Local Planning Jurisdiction)## t 66 �
Notes/Special Conditions L`o i'S f'inI n1 A)0,; ) Jokg,/ �1 G� flbU�? erE _ -p, Q.
• i>�clwc� ._,' ,+larro, o
!-e! Q n��+" 4:Yece) er�1± 1i ter ) r?6rf� cc ilk i,,,,-,
jWI,e R,c,f,-,0 ,,,4, )16f '3 1 Xc.€Cd 5 soAl&fdf:/ek .
L. I) 4' r ,,,, . , .- .
i( i'7'I vr 11'. al ti 1 .1g, hiey graidv - •
Agent or Applicant Printed Name )` ,,,,,-. ! Per itOffic r's Printed a e
F
•
Signature **Please read compliance statement on back of permit's Signature /• tj•
(� '7) -( 0e°° , f1- -`I • '51 gf '))Dt1 — - ii ---Z) 2
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:
n 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 15)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
252-264-390I Fax: 9 I 0-395-3964
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

e_ „ - ' ::1`0 a T
O B
K'CAM�4�%'DREDGE & FILL 0 79731 a , C D
GENERAL PERMIT . w{,� � 1�•�!
Previous l,4/A
> .®•New ❑Modification ❑Complete Reissue • ❑Partial.Reissue Date previous permit issued NI III '
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 I5A NCAC &±-U. POD . ('; i4 . I-,O?
©'Rules attached.
P-,
Applicant Name L • '). 'r,,, Imo?•tVI 4, Project Location: County c:,-, -- ,r--
Address
� IQ t.. \,n er�<..4 Pine Street Address/State Road/Lot#(s)
City °.4,/'t5 i 16t ( Stater+ ZIP '=:; 1;5 9 /C.)5 c<=t,,AItet'!.s± AVM' -
r� F-
Phone#(",�?1 k.1 ti�j '�.t'�,7 E-Mail "�""- Subdivision t
Authorized Agent N1 e:��V �'0(..>i.A * . City t G"1/4 4,Y1+;bra-b.44 ZIP '7
Affected ❑CW 6 EW f ,PTA "ji:Es r[PTS Phone# (ZSZ)9'f, 3`/tc.Z River Basin 1`°"4(4.,,ipellevi
AEC s : ❑OEA ❑HHF ❑IH ❑UBA ❑N/A Adj.Wtr. Body ?^i? "' `
O ❑ PWS. 1 y (ra r R U� 4(nat /man /unkn)
ORW: yes /n` PNA yes / o Closest Maj.Wtr. Body 2c'' \' c ' 2,t ve
Type of Project/Activity J.#te,44 j! -÷,100' ,&- r't Lt.,) +.�1.k4.\-°•"4.�- {'--t , IQ v.t,• , ,,^t r-,,,, ;',^v r _,A,,, ' `��<.�;,
t f � ` J P
fr.i (C�3 t,r•A,� ('i'414 VI Gt;a 1f Y' (f ' ,`",r e :XZG/r-:c.,, i ;r/1.J r'L er r� (Scale:./r/- ,fit` )
Pier(dock)length ' r,g iS'f r /4 4,'',6, `r-i,' £' , e,-+ ,
Fixed > > --' A ,- • ��—
EMIIIIMMINMENNIIMMEMEMMI
Platform(s) e 2 �C V
Floating Platform(s) ___(_ : i EN Elm ”giAii 1 1 ' , •_ ;
Finger pier(s) : 1 - —! -
Groin length, 1. 1 C; -
number 1. 1 -'_ I — ` .%„r. i°r fc4• I}, ``•_
•
Bulkhead/Riprap length IO '- I __ t NI -� } , # - a a -
CJ' -_
avg distance offshore ' i j �a RI \� ` ! a
max distance offshore 2,' I ; a a ;' !
II UQ l
Basin,channel /' —a a
d
cubic yards I NEa 11B: � IIIa a
Boat ramp —U = a a
. 1 I ,4'
Boathouse/Boatlift ! - �- - F . _ .,... II
I .
1. _
Beach Bulldozing II• ; '--} ' : �� a
Other j -i 1 �a ' a lT " e"• 1. 1-
i •: Irma eai1111111a
Shoreline Length ' /00 •IIIIIIIIIIIIIIIIIIIIMIWUWAUIIIIIIIIIIIIBIIIIIIIILIIISIIIIIIIIIIIIIIIIIIIIIIII
•
SAV: (not sure yes, no ._- • •,°....M-.•- --yw vu _._ *� ` ie./ a
Moratorium: n/a yes no`, , % • i .'„ t r�/ � 1- i 14' \-,
Photos: ' yes no, tIti_. c.:.,.,,,,!.,:- - - k� ' ? j2. _ 1
2
Waiver Attached: ' Oyes` no 1 1 4.a -M.
•
A building permit may be required by: .51tU4 �'T ".3 • . NI See note on'back regarding River Basin rules.
(Note Local Planning Jurisdiction) ,
` . ,
� f
Notes/Special Conditions �j(7f I S ('1'`'irlt(n4-/nlw,er} t/0i✓)1.e / ►I l fo/.1'1'7 1(/ _ t `.
e.' On 1. `�1. <rX.Cc.'k''",'% eek1:5 pm, 17!C'';r'. 1( 4h'' 41 v Sr 4:-, *z eyw.
,mac ':�'
.10 VA, • rR.t"f,,;x 40.. - ryil.': i'4`v...f s e 4 A).a•I'',4E;"el -
/ ¢ %t ,
i. `( l t� 1�//��f .. 1 i, l,)?,1 1 ( :,�;.`V �V
Agent or Applicant Printed Name PermitOfficer's Printed
f]Naame
(....P&I ' )Aty'
/..1-'-----"XXji. ,
Si nature **Please read com liance statement on back of permit Signature g! , ?,'. ' '4411°dB 2 '°"-' , . 1 1. .�-I -7 ` +t' " -- 01-1 - , ' ,y,� -7„C�2,." ,
Application Feels) 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:
n Tar-Pamlico River Basin Buffer Rules I I 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 0-796-7215)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 252-946-648 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
252-264-390I 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 028.0233 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.
5. 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 tb
this shoreline stabilization project must be restored with woody vegetation eta stern density of 260 sterns per acre.
Non wooded sites may be re-vegetated with woody vegetation. Restoration must be completed by the first
subsequent planting season (November/J 1 through March 30 after mple on of the bulk ead. i
a Pre-project site conditions: /moo /S �4,&, lie) '(PP) ''i/ GDP 4 47(e,
7. Project Drawing:The drawing on the CAMA General Permit is considered the project rawing of your property
indicating the location of the shoreline stabilization structure and any associated 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 abo lis e conditions veri hat all
information is complete and accurate.
Re&1L Se
A esot or A plica Printed Name Permit Off' erg nature
Agent or Applicant Signature IssueIssue ate (i
CAMA GEC:ERAL PERMIT##: 7 T7/
State of North Carolina I Environmental Quality I Coastal Management
Washington Office 1943 Washington Square Mall Washington,NC 2781391252-946-6481
Wilmington Office 1 127 Cardinal Drive Evt.W;1mington NC 26405-3.845I 910-796_7L15
Morehead City Office 1400 Commerce Avenue Morehead City.NC 28557 1252-808-2808

ADJACENT RIPARIAN PROPERTY OWNER
/STATEMENT
I hereby certify that I own property adjacent to L 4Uoe* U. 0 -U 15 's
property located at t d S S oc 4A 17I ST 4 u, (Name of Property Owner)
(Address, Lot,Block, Road, etc.)
on Pm 1 (Co /ei UL-72. , in Li/ii-5,►i NG-Tait 0LiNt'Fafr , N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location..
4./. I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(IndiMMdilal 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, rift, 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
(Property"Owner Information) (Adjacent Property Owner Information)
L o. e.scv.,, r,„,,„fei„
S � Si tore
I L Ir a-(6-L- p -o s . S'k p vV G r `c(/
Print or y e Namet y Print or Type Name
1 o 5 50v111 E-Asrif v< t 0.2) & 4 pt-S- .
Mat gs/�ddress
/ 2 :��7 Maili sd s� 2 lY
�} /�cN&-rep- 'V,
City/State/Zip City/State/Zip Q�
252.- q 9- 3'46Z e2.s2- /(4,3'�7GI
Telephone Number/email address Telephone Number/email address
A►4 `/ /S / 2_20 Z) �!%rGcc l /S .2 002(
Date Date* G
(Revised Aug. 2014)
*valid for one calendar year after signature*

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to L. 4(%'f.?- A 40 r.5 's
property located at I D 5 covfh 1/9s y hot (Name of roperty Owner)
(Address, Lot, Block, Road, etc
on 'm)rCO /9<<i z. , in IPof1)4,6-Toy/ 19'U4'G2 r , N.C.
(Waterbody) (City/Town 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)
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.)
17-
I do wish to waive the 15'setback requirement.
I do not wish to waive the 15'setback requirement
(Property Owner Information) (Adjacent Property Ow er Information)
/reup2-‘ Pan.v;
SigLnatur�t91 - AfiLs Iletr4ir or Type Name Print or Type Name ,
f0S 5 0 011 1114Sr b 1 o 8 cap wry 61 Or 7/31916lf
mailing Address M 'ing Address J
woc/,11 c�-7-oti /✓C� 2'? ?' I�� 6. 1 N �f fo 1 �i
City State/ZI City/Staf
�$2— 45—� ce19 OP'lrk3Y
Telephone Number/email address Telephone Number/email address
12-61.1 21 ' I7L, )2-1
Date Date*
(Revised Aug.2014)
*Valid for one calendar year after signature*

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to L 1(�/Z,4 e li-[1 i 'S
p p rtylQr )cX/ rb /�� ame oroperly Owner)
roe located at S. �l f
(Address, Lot, Blgck, Road, etc.)
on it/A hi to I r(>tE , in 1s`j G-TO r LP r N [:7�U�U? , N.C.
(Waterbody) (City/Town and/or County)
The applican has described to me, as shown below, the development proposed at the above
locati n.
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
(Property Owner Information) (Adjacent Property Owner Information)
t ri r
i i ?411.1, /jadi, LIU ad \0 i e I I e,t-d 0(0)1)AM U.)
Sigr�atur Si [ture*
L. , 174,7r-i j9,19�v s ei va rev Lapure,nc
Prin or Type Na Print or Type Na e!
• I ,oS arfheifsr i9-� qll Ave. exf
M��J/1/n ddress Mailing A dress y�
v /15ArNlyTewL ZI17 YO5� In YUn tom. 4`7g�q
City/State/Zip CAs1
/State/Zip 0
25.2- cty9- 3ttky- - '7— 9g-lq
Telephone Number/email address Telep one N mber/email address
5f3oi21 .5 .3D/ )
Date Dat
(Revised Aug. 2014)
*Valid for one calendar year after signature*

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
gm orf, No_() 1—
I hereby certify that I own property adjacent to f 11 oaEMt $h p2 C=S PS 5 o L,l4-T 10 n?j s ��s
(3s4wcEN (Name of Property Owner)
4
property located.at io s 5OhBFsr Aaif CI!/ A14,4 4(3 5144 R(//fq
/J (Address, Lot, Block, Road, etc.
on !'e1A1 (ico , in W*Sh. /1/, Z. l!4-UFDAr , N.C.
(Waterbody) (City/Town 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)
•
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.
t/' I do not wish to waive the 15' setback requirement.
(Property Owner Information) (Adjacent Property Owner Information)
etiliz. 0 c447
Si nature Si ature*
L /1 � U'�5 oo G�
Print or Type Name Print or Type Name
(OS Soo-M E 4 5 r /1v. ,2/1p hlo c 5116 res
M ilmg Address Ma'ing Addr ss
W05b.A/G•roA) n�c. 27frEcT wosk,„qt �•fC a- we,
City/State/Zip City/State/Zip
252 — 3462 c. .02501-q45-()6,5 - 5Srio►(eea31e(pla.g.6M
Telephone Number/email address Telephone Number/email ad ress
Date
5 ,1 Q l/zi p,4-frf 5/11/f,? -I
Date
(Revised Aug. 2014)
*Valid for one calendar year after signature*

•
•
Al •
•

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: Z t /i (r Ui 9 U I .S
Mailing Address: 16 5 josh Fos r 4v,
(//R5Ai ,v&TOri A/ z. 21n7
Phone Number: 2 5 2 - 414 5— 4 yG 2
Email Address: PO4 0 $ ( 5 V A Craocrr. tGrr)
I certify that I have authorized IL A. c pilous e- c7R. f 1Mi 'ic 40)57RtzTioni
Agent/Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
at my property located at 165 5oo1A b lqS hot
in Ell0F0RT 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:
/ d
Signature
1.i gich•&-t:' /,9. /S
Print or Type Name
Title
6 I I2. 1
Date
This certification is valid through I I