HomeMy WebLinkAboutSC_20-06_ Uzzell SC20-06
Issued by WiRO Permit Number
Surf City
CAMA 4,41:11.'
4°`
4
MINOR DEVELOPMENT
PERMIT NORTH CAROLINA
Environmental Quality
as authorized by the State of North Carolina, Department of Environmental Quality
and the Coastal Resources Commission for development in an area of environment
concern pursuant to Section 113A-118 of the General Statutes, "Coastal Area
Management"
Issued to William Uzzell, Ill authorizing development in the Estuarine Shoreline Area of Environmental Concern (AEC)
at 4085 4th Street, in Surf City, Pender County as requested in the permittee's application dated January 24, 2020, and
received by DCM on January 27, 2020. This permit, issued on February 12, 2020, is subject to compliance with the
application and site details (where consistent with the permit), all applicable regulations and special conditions and notes
set forth below. Any violation of these terms may subject permittee to a fine, imprisonment or civil action, or may cause
the permit to be null and void.
This permit authorizes: Clearing and grading of lot.
(1) All proposed development and associated construction must be done in accordance with the application package dated
received by the Division of Coastal Management on January 27, 2020. This permit does not authorize the creation of any
new structures(i.e.dwellings,driveways,docks, etc.)
(2) All construction must conform to the N.C. Building Code requirements and all other local, State and Federal regulations,
applicable loca;ordinances and FEMA Flood Regulations.
(3) Any change or charges in the plans for development, construction, or land use activit`.es will require a re-evaluation and
modification of this permit.
(4) A copy of this permit shall be posted or available on site. Contact this office at (910) 766-7221 for a final inspection at
completion of work.
(Additional Permit Conditions on Page 2)
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This permit action may be appealed by the permittee or other qualified persons >
within twenty (20)days of the issuing date. This permit must be on the project Ja n Dail — z CZ
site and accessible to the permit officer when the project is inspected for MA Local Permit Offic 2 1-4
compliance. Any maintenance work or project modification not covered under 127 Cardinal Drive Exten I n= m
this permit,require further written permit approval.All work must cease when this LW
permit expires on: Wilmington, NC 28405-3i 5`}
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December 31,2023 IC P• t j,Lft /1.
In issuing this permit it is agreed that this project is consistent with the local Land
I Ica Plan anti all annlirahle nrriinanras This nermit may not he transferred to PPPMITTPP
Name: William Uzzell, Ill
Minor Permit#SC20.06
Date Issued: February 12, 2020
Page 2
(5) All unconsolidated material resulting from associated grading and landscaping shall be retained on site by effective
sedimentation and erosion control measures. Disturbed areas shall be vegetated and stabilized (planted and
mulched)within 14 days of construction completion.
(6) Any proposed for grading within the 30' buffer from the Normal High Water level must be contoured to prevent
additional stormwater runoff to the adjacent marsh and/or canal. This area shall be immediately vegetatively
stabilized, and must remain in a vegetated state.
(7) No structures shall be located within the 30' Coastal Shoreline buffer.
(8) This permit does not authorize the excavation or filling of any wetlands or open water areas.
(9) Pursuant to 15A NCAC, Subchapter 7J.0406(b), this permit may not be assigned, transferred, sold or otherwise
disposed of to a third-party.
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CAI) G O r✓ OTHER PERMITS MAY BE REQUIRED:The activity you are planning may require permits other than the CAMA
Locality Cj/v'" Permit Number minor development permit,including,but not limited to:Drinking Water Well,Septic Tank(or other sanitary waste
treatment system),Building,Electrical,Plumbing,Heating and Air Conditioning,Insulation and Energy Conservation,FIA
Ocean Hazard Estuarine Shoreline ORW Shoreline Public Trust Shoreline Other Certification,Sand Dune,Sediment Control,Subdivision Approval,Mobile Home Park Approval,Highway Connection,and
(For official use only) others.Check with your Local Permit Officer for more information.
GENERAL INFORMATION STATEMENT OF OWNERSHIP:
I,the undersigned,an applicant for a CAMA minor development permit,being either the owner of property in an AEC or a
LAND OWNER person authorized to act as an agent for purposes of applying for a CAMA minor development permit,certify that the person
Name William E.Uzzell,Ill listed as landowner on this application has a significant interest in the real property described therein.This interest can be
described as:(check one)
Address 3047 3rd Street
ran owner or record title,Title is vested in Fee Simple ,see Deed Book 5041/213 and 5041/2
Surf City Y State NC Zip 28445 Phone (910)455-0877 page in the Onslow County Registry of Deeds.
Email euzzell12@gmail.com
ran owner by virtue of inheritance.Applicant is an heir to the estate of ,
AUTHORIZED AGENT probate was in County.
Name Charles F.Riggs&Associates,Inc. 1--If other interest,such as written contract or lease,explain below or use a separate sheet&attach to this application.
Address P.O.Box 1570 NOTIFICATION OF ADJACENT PROPERTY OWNERS:
City Jacksonville State NC Zip 28541 Phone (910)455-0877 I furthermore certify that the following persons are owners of properties adjoining this property.I affirm that I have given
ACTUAL NOTICE to each of them concerning my intent to develop this property and to apply for a CAMA permit.
Email riggsland@riggslandnc.com
(Name) (Address)
(l) Ms.Beatrice B.Rivenbark,588 Stratford Drive,Blue Ridge,VA 24064
LOCATION OF PROJECT:(Address,street name and/or directions to site.If not oceanfront,what is the name of the
adjacent waterbody.) 4085 4th Street,Surf City,Onslow County (2) Mr.and Mrs.Lincoln B.Scott,4089 4th Street,Surf City,NC 28445
DESCRIPTION OF PROJECT:(List all proposed construction and land disturbance.) Proposed Clearing, (3)4
Grubbing and Grading of Property
SIZE OF LOT/PARCEL: 6,423 square feet 0.147 acres ACKNOWLEDGEMENTS:
I,the undersigned,acknowledge that the land owner is aware that the proposed development is planned for an area which
PROPOSED USE:Residential 0 (Single-family ID Multi-family❑) Commercial/Industrial❑ Other 0 may be susceptible to erosion and/or flooding.I acknowledge that the Local Permit Officer has explained to me the particu-
lar hazard problems associated with this lot.This explanation was accompanied by recommendations concerning stabiliza-
COMPLETE EITHER(1)OR(2)BELOW(Contact your Local Permit Officer ifyou are not sure which AEC applies tion and floodproofing techniques.
to your property):
I furthermore certify that I am authorized to grant,and do in fact grant,permission to Division of Coastal Management staff,
(1) OCEAN HAZARD AECs:TOTAL FLOOR AREA OF PROPOSED STRUCTURE:N/A square feet(includes the Local Permit Officer and their agents to enter on the aforementioned lands in connection with evaluating information
air conditioned living space,parking elevated above ground level,non-conditioned space elevated above ground level but related to this permit application.
excluding non-load-bearing attic space) /
fo
(2) COASTAL SHORELINE AECs:SIZE OF BUILDING FOOTPRINT AND OTHER IMPERVIOUS OR BUILT This the day of�/,/P ,20
UPON SURFACES:NiA square feet(includes the area of the roof/drip line of all buildings,driveways,covered decks,
concrete or masonry patios,etc.that are within the applicable AEC.Attach your calculations with the project drawing.)
Landowner or persaki,401
to. as hi Wurpose of filing a CAMA permit application
STATE STORMWATER MANAGEMENT PERMIT:Is the project located in an area subject to a State Stormwater
Management Permit issued by the NC Division of Water Quality? This application includes:gener I in,rmati,n(this inn),a site drawing as described on the back of this application,the
YES F 1 NCd ✓ I ownership statement,the Ocean azar - Notice here necessary,a check for$100.00 made payable to the locality and
any information as may be provide. ...![,b t - -.plicant.The details of the application as described by these sources are
If yes,list the total built upon area/impervious surface allowed for your lot or parcel: square feet. incorporated without reference in any permit which may be issued.Deviation from these details will constitute a violation of
RE C E%V E D any permit.Any person developing in an AEC without permit is subject to civil,criminal and administrative action.
DCM WILMINGTON, NC
JAN 2 7 2020
SITE DRAWING/APPLICATION CHECKLIST
Please make sure your site drawing includes the following information required for a CAMA minor development permit.
The Local Permit Officer will help you,if requested.
PHYSICAL/DIMENSIONS p( A! APPLICATION ION FOR
to
,.Label roads
, CAMA MINOR
Label highways right-of-ways g
_4abel local setback lines
�L.abel any and all structures and driveways currently existing on property DEVELOPMENT
Label adjacent waterbody
PHYSICAL CHARACTERISTICS )C PERMIT
w and label normal high water line(contact LPO for assistance)
f Draw location of on-site wastewater system In 1974,the North Carolina General Assembly passed the Coastal Area Management Act
(CAMA)and set the stage for guiding development in fragile and productive areas that
If you will l�working in the ocean hazard area: border the state's sounds and oceanfront.Along with requiring special care by those who
aw and label dune ridges(include spot elevations) build and develop,the General Assembly directed the Coastal Resources Commission
draw and label toe of dunes (CRC)to implement clear regulations that minimize the burden on the applicant.
/Identify and locate first line of stable vegetation(contact LPO for assistance)
—1"Draw and label erosion setback line(contact LPO for assistance) This application for a minor development permit under CAMA is part of the
Draw and label topographical features(optional) Commission's effort to meet the spirit and intent of the General Assembly.It has been
designed to be straightforward and require no more time or effort than necessary from
If you will be working in a coastal shoreline area: the applicant.Please go over this folder with the Local Permit Officer(LPO)for the
Show the roof overhang as a dotted line around the structure locality in which you plan to build to be certain that you understand what information he
/Draw and label landward limit of AEC or she needs before you apply.
aw and label all wetland lines(contact LPO for assistance)
Draw and label the 30-foot buffer line Under CAMA regulations,the minor permit is to be issued within 25 days once a
DEVELOPMENT PLANS complete application is in hand.Often less time is needed if the project is simple.The
process generally takes about 18 days.You can speed the approval process by making
iHraw and label all proposed structures certain that your application is complete and signed,that your drawing meets the
/Draw and label areas that will be disturbed and/or landscaped specifications given inside and that your application fee is attached.
/Note size of piling and depth to be placed in ground
Draw and label all areas to be paved or graveled Other permits are sometimes required for development in the coastal area.While these
Show all areas to be disturbed are not CAMA-related,we urge you to check with the Local Permit Officer to determine
Show landscaping
which of these you may need.A list is included on page two of this folder.
NOTE TO APPLICANT
We appreciate your cooperation with the North Carolina Coastal Management Program
Have you: and your willingness to build in a way that protects the resources of our beautiful and
• completed all blanks and/or indicated if not applicable? productive coast.
• notified and listed adjacent property owners?
• included your site drawing?
Coastal Resources Commission
• signed and dated the application? Division of Coastal Management
• enclosed the$100.00 fee?
• completed an AEC Hazard Notice,if necessary?(Must be signed by the property owner)
FOR STAFF USE
tri Site Notice Posted_Final Inspection Fee Received r
Site Inspections ❑
00;
Date of Action:Issued Exempted _.�:'x,G EI adline(20 days from permit action) DCM Form 5B1952-2010 Revised April 2010
DCM WILMINGTON, NC
JAN 2 7 2020
ROY COOPER
itt$tGovernor
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\ _
MICHAEL S. REGAN
see,.,•« ',
BRAXTON DAVIS
')irector
February 12, 2020
William Uzzell, Ill
3047 3rd Street
Surf City, NC 28445
Dear Mr. Uzzell,
Attached is CAMA Minor Development Permit SC 20-06 for work to be done at 4085 4th Street in Surf
City,Onslow County. An electronic copy has been sent to the Surf City Inspections Department and your
Agent.
To validate this permit, please sign both copies as indicated for our records. Retain the orange copy for
your files, and return the white copy to us within 20 days of receipt in the enclosed, self-addressed
envelope.
This is not a valid permit until it is signed and returned to our office.
Thank you for your prompt attention to this matter.
Sincerely,
UAAI\
Tanya K. Diet a
'ermit Suyp ort Technician
N.C. Division of Coastal Management
Enclosures
Cc: WiRO files
SC Inspection Dept.
Charles Riggs—Agent
State of North Carolina I Environmental Quality I Coastal Management
127 Cardinal Drive Ext.,Wilmington,NC 28405
CHARLES F. RIGGS &ASSOCIATES, INC.
Land Surveyors
Charles F.Riggs,P.L.S.L-2981 Corporate License(C-730) James A.Lewis,P.L.S.L-4562
502 New Bridge Street 502 New Bridge Street Landfall Executive Suites
Jacksonville,North Carolina 28540 P.O.Box 1570 1213 Culbreth Drive
(910)455-0877 Jacksonville,North Carolina 28541 Wilmington,North Carolina 28405
charlesriggs@riggslandnc.com (910)455-0877 (910)681-7444
jameslewis@riggslandnc.com
January 24,2020
To: Mr. Jason Dail
Division of Coastal Management
North Carolina Department of Environmental Quality
127 Cardinal Drive
Wilmington,North Carolina 28405
Re: William E. Uzzell, III Submittal for Minor CAMA Permit
Dear Mr. Dail:
On behalf of William E. Uzzell, III,Charles F. Riggs&Associates, Inc. submits for your review the
enclosed application for a Minor CAMA permit for the property at 4085 4th Street, Surf City,Onslow
County,North Carolina.
Respectfully,
, ames L. Riggs
RECEIVED
DCiv1 WILMINGTON, NC
JAN 2 7 2020
CHARLES F. RIGGS & ASSOCIATES, INC.
Land Surveyors
Charles F.Riggs,P.L.S.L-2981 Corporate License(C-730) James A.Lewis,P.L.S.L-4562
502 New Bridge Street 502 New Bridge Street Landfall Executive Suites
Jacksonville,North Carolina 28540 P.O.Box 1570 1213 Culbreth Drive
(910)455-0877 Jacksonville,North Carolina 28541 Wilmington,North Carolina 28405
charlesriggs@riggslandnc.com (910)455-0877 (910)681-7444
jameslewis@riggslandnc.com
January 24,2020
Ms. Beatrice B. Rivenbark
588 Stratford Drive
Blue Ridge, VA 24064
Re: William E. Uzzell, Ill ubmittal for Minor CAMA Permit
Dear Ms. Rivenbark:
On behalf of William E. Uzzell, III,Charles F. Riggs& Associates, Inc. is submitting to the Division
of Coastal Management,North Carolina Department of Environmental Quality the enclosed application
for a CAMA permit for the property located at 4085 4th Street, Surf City,Onslow County,North Carolina.
William E. Uzzell, III is proposing the clearing,grubbing and grading of the property. We are required to
notify the adjoiners of this submittal. if you have objections, please send your comments in a timely
fashion to Mr.Jason Dail, Division of Coastal Management,N.C. Department of Environmental Quality,
127 Cardinal Drive, Wilmington,NC 28405 or by phone at(910)796-7221 or e-mail at
jason.dail@ncdenr.gov.
Respectfully,
1:)9.
r � l
Vames L. Riggs
RECEIVED
0CM WILMINGTON, NC
JAN 2 7 LO20
U.S. Postal Service'"'
CERTIFIED MAIL° RECEIPT
q Domestic Mail Only
n For delivery information,visit our website at www.usps.com'.
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delivery. LISPS®-postmarked Certified Mail receipt to the
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for a specified period. delivery to the addressee specified by name,or
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important Reminders: -Adult signature service,which requires the
I You may purchase Certified Mall service with signee to be at least 21 years of age(not
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r Insurance coverage Is notavallable for purchase by name,or to the addressee's authorized agent
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of Certified Mail service does not change the •To ensure that your Certified Mail receipt is
insurance coverage automatically included with accepted as legal proof of mailing,it should bear a
certain Priority Mail items. USPS postmark.If you would like a postmark on
I For an additional fee,and with a proper this Certified Mail receipt,please present your
endorsement on the mallpiece,you may request Certified Mail item at a Post Office-for
the following services: postmarking.If you don't need a postmark on this
-Return receipt service,which provides a record Certified Mail receipt,detach the barcoded portion
of delivery(including the recipient's signature). of this label,affix it to the mailpiece,apply
You can request a hardcopy return receipt or an appropriate postage,and deposit the mailpiece.
electronic version.For a hardcopy return receipt,
complete PS Form 3811,Domestic Return
Receipt'attach PS Form 3811 to your mailpiece; IMPORTANT.Save this receipt for your records.
1C Fnrm 3Rf1I_Anril'Jf11 5 Mallorca,PCIU 75'U1119Nilona7
• CHARLES F. RIGGS &ASSOCIATES, INC.
Land Surveyors
Charles F.Riggs,P.L.S.L-2981 Corporate License(C-730) James Ai Lewis,P.L.S.L-4562
502 New Bridge Street 502 New Bridge Street Landfall Executive Suites
Jacksonville,North Carolina 28540 P.O.Box 1570 1213 Culbreth Drive
(910)455-0877 Jacksonville,North Carolina 28541 Wilmington,North Carolina 28405
charlesriggs@riggslandnc.com (910)455-0877 (910)681-7444
jameslewis@riggslandnc.com
January 24,2020
Mr. and Mrs. Lincoln Scott
4089 4th Street
Surf City,NC 28445
Re: William E. Uzzell, Ill ubmittal for Minor CAMA Permit
Dear Mr. and Mrs. Scott:
On behalf of William E. Uzzell, IIl,Charles F. Riggs&Associates, Inc. is submitting to the Division
of Coastal Management,North Carolina Department of Environmental Quality the enclosed application
for a CAMA permit for the property located at 4085 4th Street, Surf City,Onslow County,North Carolina.
William E. Uzzell, III is proposing the clearing,grubbing and grading of the property.We are required to
notify the adjoiners of this submittal. If you have objections,please send your comments in a timely
fashion to Mr.Jason Dail, Division of Coastal Management,N.C. Department of Environmental Quality,
127 Cardinal Drive, Wilmington,NC 28405 or by phone at(910) 796-7221 or e-mail at
jason.dail@ncdenr.gov.
Respectfully,
/Il�ti'A i7
James L. Riggs
REGEIN/'EID
DCM WILMINGTON, NC
JAN 2 7 2020
1. . Posta ervice
CERTIFIED MAIL® RECEIPT
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✓ For delivery information,visit our website at www.usps.com .
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1 A receipt(this portion of the Certified Mall label). for an electronic return receipt,see a retail
I A unique identifier for your mailpiece. associate for assistance.To receive a duplicate
I Electronic verification of delivery or attempted return receipt for no additional fee,present this
delivery. USPS®-postmarked Certified Mail receipt to the
1 A record of delivery(including the recipients retail associate.
signature)that is retained by the Postal Service'" -Restricted delivery service,which provides
for a specified period, delivery to the addressee specified by name,or
to the addressee's authorized agent.
'warrant Reminders: -Adult signature service,which requires the
1 You may purchase Certified Mail service with signee to beat least 21 years of age(not
First-Class Mail®,First-Class Package Service°, available at retail).
or Priority Mail®service. -Adult signature restricted delivery service,whist
I Certified Mail service is notavailable for requires the signee to be at least 21 years of ag
international mail. and provides delivery to the addressee specified
'Insurance coverage Is not available for purchase by name,or to the addressee's authorized agent
with Certified Mail service.However,the purchase (not available at retail).
of Certified Mail service does not change the •To ensure that your Certified Mail receipt is
insurance coverage automatically included with accepted as legal proof of mailing,it should bear
certain Priority Mail items. USPS postmark.If you would like a postmark on
I For an additional fee,and with a proper this Certified Mail receipt,please present your
endorsement on the mailpiece,you may request Certified Mail item at a Post Office-for
the following services: postmarking.If you don't need a postmark on this
-Return receipt service,which provides a record Certified Mail receipt,detach the barcoded portion
of delivery(including the recipient's signature). of this label,affix it to the mailpiece,apply
You can request a hardcopy return receipt or an appropriate postage,and deposit the mailpiece.
electronic version.For a hardcopy return receipt,
complete PS Form 3811,Domestic Return
Receipt attach PS Form 3811 to your mailpiece; IMPORTANT:Save this receipt for your records.
,0 e,,,.,,2R0fl_Anti!'nu iao,.e eal DCA,74,2n_n0J1nn
CHARLES F. RIGGS &ASSOCIATES, INC.
Land Surveyors
Charles F.Riggs,P.L.S.L-298I Corporate License(C-730)
502 New James A. Lewis,P.L.S.L.4562
5 2 New Bridgei e Streetth Carolina 28540 502 New Bridge Street Landfall Executive Suites
.lacks 455-0877 P.O.Box 1570 1213 Culbreth Drive
(910) Jacksonville.North Carolina 28541 Wilmington.North Carolina 28405
charlesriggsriggslandne.com (910)455-0877 (910)681-7444
.jameslewis( riggslandnc.corn
AGENT AUTHORIZATION FORM
Date: January 24,2020
Name of Property Owner Applying for Permit:
William E. Uzzell III
Mailing Address:
3047 3rd Street
Surf City, NC 28445
I certify that I have authorized Charles F. Riggs & Associates, Inc. to act on my behalf, for the purpose
of applying for and obtaining all CAMA Permits necessary for clearing,grubbing and grading of property,as
shown on attached map and located at 4085 4th Street, Surf City, Onslow County,North Carolina,and I grant
permission to the Division of Coastal Management to access the property to mark/flag:
j/The First Line of Stable Natural Vegetation
L/yie Coastal Wetlands
17 The Normal High Water Line
This authorization is valid thru January 24,2021
4, January24
Property Owner Signature i 2020
Date
RECEIVED
DCM WILMINGTON, NC
JAN 2 7 2020
OCEAN HAZARD AEC NOTICE
Project is in an: Ocean Erodible Area High Hazard Flood Area Inlet Hazard Area
Property Owner: William E.Uzzell,Ill
Property Address: 4085 4th Street,Surf City,Onslow County
Date Lot Was Platted: February 1969
Ibis notice is intended to make you. the applicant. aware of the SPECIAL NOTE: This hazard notice is required for
special risks and conditions associated with development in this development in areas subject to sudden and massive storms and
area.which is subject to natural hazards such as storms,erosion
erosion. Permits issued for development in this area expire on
and currents. The rules of the Coastal Resources Commission December 31 of the third year following the year in which the
require that you receive an AEC Hazard \otice and permit was issued. Shortly before work begins on the project
acknowledge that notice in writing before a permit for site.the Local Permit Officer must be contacted to determine the
development can he issued. vegetation line and setback distance at your site. If the property
has seen little change since the time of permit issuance, and the
The Commission's rules on building standards, oceanfront proposed development can still meet the setback requirement.
setbacks and dune alterations arc designed to minimize. hut not the LPO will inform you that you may begin work. Substantial
eliminate, property loss from hazards. By granting permits, the progress on the project must be made within 60 days of this
Coastal Resources Commission does not guarantee the safety of setback determination,or the setback must be re-measured.Also.
the development and assumes no liability for future damage to the occurrence of a major shoreline change as the result of a
the development. Permits issued in the Ocean Hazard Area of storm within the 60-day period will necessitate re-measurement
Environmental Concern include the condition that structures be of the setback. It is important that you check with the LP()
relocated or dismantled if they become imminently threatened before the permit expires for official approval to continue the
by changes in shoreline configuration. The structure(s)must be work after the permit has expired. Generally, if foundation
relocated or dismantled within two (2) years of becoming pilings have been placed and substantial progress is continuing.
imminently threatened. and in any case upon its collapse or permit renewal can be authorized. It is unlawful to continue
subsidence. work after permit expiration.
the best available information.as accepted by the Coastal
Resources Commission, indicates that the annual long-term F°rntoretnj°rnwHon,cortract:
average ocean erosion rate for the area where your property is
located is feet per year.
I he rate was established by careful analysis of' aerial I tx,al Permit Officer
photographs of the coastline taken over the past 50 years.
Studies also indicate that the shoreline could move as much as Address
feet landward in a major storm.
The flood waters in a major storm arc predicted to be about
feet deep in this area. Locality
Preferred oceanfront protection measures are beach nourishment
and relocation of threatened structures. Hard erosion control
structures such as bulkheads,seawalls,revetments•groins.jetties Phone Number
and breakwaters are prohibited. temporary sand bags may be
authorized under certain conditions.
the applicant must acknowledge this information and
requirements by signing this notice in the space below. Without
the proper signature,the application will not be complete.
Property Owner Signat Date
Revised Ma 2010
RECEIVED
DCM WILMINGTON, NC
I A hl 9 7 anon
Iiiih NC Division of Coastal Management 10950 A B C
Cashier's Official Receipt O
Date: / i" Zei
20
atit4"1/4 , 46V_____—
Received From: P12/2
$
Permit No.: I Check No.:
Applicant -*If's ems' Alit I'( � l'K � County: 1 e
PP s Name: ✓ tY
Project Address: 4' 75— 1,it ::
5
Please retain receipt for your records as proof of payment for permit issued.
Signature of Agent or Applicant: Date:
• r
Signature of Field Representati . Date:
Date Date Check From Name of Vendor Check Check Permit Rct
Received Deposited Permit Holder Number amount Number/Comments
1/28/2020 Charles F. Riggs William Uzzell First 16357 $100.00 minor fee,4085 4th St,Surf City JD rct
and Associates Inc. Citizens OnCo 1095C
Bank