CB_04-22_Cooke

__Town of Carolina Beach_
Local Government
MINOR DEVELOPMENT
PERMIT
as authorized by the state of North Carolina, Department of Environment,
and Natural Resources and the Coastal Resources Commission for development
in an area of environment concern pursuant to section 113A-118 of the
General statues, "Coastal Area Management'
CB2004-22--_
Permit Number
Issued to ___Harold Cooke ____ - ______ , authorizing development in Ocean Hazard— ____ at _1410
Carolina Beach Ave. N _ as requested in the permittee's application, dated May 5.
2004 . This permit, issued on May 25, 2004 , is subject to compliance with the application and
site drawing (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
(1) All proposed development and associated construction must be done in accordance with the permitted
work plat drawings(s) dated received 5/25/04
(2) All construction must conform to the N.C. Building Code requirements and all other local, State and
Federal regulations, applicable local ordinances and FEMA Flood Regulations.
(3) Any change or changes in the plans for development, construction, or land use activities will require a
re-evaluation and modification of this permit.
(4) This Permit is valid for the Demolition of a single family home at 1410 Carolina Beach Ave N.
(5) Pursuant to NCAC, Subchapter 7J.0406(b), this permit may not be assign erred, or. otherwise
disposed of to a third party.
(6) All disturbed areas shall be vegetatively planted and mulched 30 day�y�rttction
completion. C' G �i/�
This permit action may be appealed by the perniftee or other
qualified persons within twenty (20) days of the issuing dale. From
the date of an appeal, any work conducted under this permit must
cease until the appeal is resolved.
This permit must be on the project site and accessible to the permit
officer when the project is inspected for compliance.
Any maintenance work or project modification not covered under
this permit, require further written permit approval.
All work must cease when this permit expires on December 31,
In issuing this permit it is agreed that this project is consistent with
the local Land Use Plan and all applicable ordinances.
This permit may not be transferred to another party without the
written approval of the Division of Coastal Management.
(� v\ n_`S/n _ Y
Pernittee (signature required if conditions above apply to permit)

Locality Permit Number
Please
permi
reque!
PHY'
PHY'.
Ocean Hazard _ Estuarine Shoreline _ORW Shoreline Public Trust Shoreline _Other
GENERAL INFORMATION
LAND OWNER
(For official use only)
✓UN n �y�.
F^� n • fin_
Name Hint C4 CgxA*- "t• '
Address yi(„ 5%b4 Lti 4 b
City Gru -fiboro State 14C Zip 7-"01e
--AUTHORIZED AGENT
to" -
If you Name tEWF CWr%5+rule Ce Iwra•
Address V= N " ifs■ K SkIO
City carnlil-A 16CAO- Stare Mt Zip 2sA2A Phone X156 "AGMFO
LOCATION OF PROJECT (Address, street name and/or directions to site. if not oceanfront, what is the name of
If you the adjacent waterbody?) __ [ft CAK616A &ar-6 AVt N
DEVI DESCRIPTION OF PROJECT (List all proposed construction and land disturbance.)
Deo"011%% "isvoi ometur t dw. }o_Aoe.
SIZE OF LOTMARCEL. 62, 0 square feet .14 acres
PROPOSED USE: Residential_ (Single-family Y_ Multi -family _) Commerical/Industrial
Other
NOT TOTAL ENCLOSED FLOOR AREA OF A BUILDING IN THE OCEAN HAZARD AREA OF ENVI-
RONMENTAL CONCERN (AEC): square feet (includes all Floors and roof -covered decks)
Have
SIZE OF BUILDING FOOTPRINT AND OTHER IMPERVIOUS OR BUILT -UPON SURFACES IN
THE COASTAL SHORELINE AREA OF ENVIRONMENTAL CONCERN (AEC): 300T sq. f .
(Calculations include 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.)
Choose the AEC area that applies to your property
(1) within 75 feet of Normal High Water for the Estuarine Shoreline AEC
(2) within 575 feet of Normal High Water for the Estuarine Shoreline AEC, adjacent to Outstanding
Resource Waters
Si (3) within 30 feet of the Public Trust Shoreline AEC
Si (Contact your Local Permit Officer if you are not sure which AEC applies to your property.)
_ STATE STORMWATER MANAGEMENT PERMIT- Is the project located in an area subject to a
State Stormwater Management Permit issued by the N.C. Division of Water Quality?
- YES NO 9
Dat If yes, list the total built -upon area/impervious surface allowed for your lot or parcel. square feet.

OTHER PERMITS MAY BE REQUIRED: The activity you are planning may require permits other than the CAMA minor
development permit. As a service the have compiled a list of the kinds of permits that might be required. We suggest you check over the list
with ,your LPO to determine if any of these apply to your project: "Liming, Drinking Water Well, Septic Tank (or other sanitary waste
treatment system), Burning, Electrical, Plumbing, Heating and Air Conditioning, Insulation and Energy Conservation, FIA Certification,
Sand Dune, Sediment Control, Subdivision Approval, Mobile Home Park Approval, Highway, Connection, and others.
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
person authorized to act as an agent for purposes of applying for a CAMA mi development permit, certify that the person
listed as landowner on this application has a significant interest in the real p f�bed therein. This interest can be
described as: (check one) 6 .t' 7^
X an owner or record title. Title is vested in
page in the
, see tee
County Registry of s.
_an owner by virtue of inheritance. Applicant is an heir to the estate of
probate was in County.
_if other interest, such as wrirten contract or lease, explain below or use a separate sheet and at6kh to this application.
NOTIFICATION OF ADJACENT, PROPERTY OWNERS:
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.
(Name) (Address)
(1) A1�1er 6ldtw4e._3 ,
(2) Daowd K&wial Po 6W 151e0 rCarel'.an C34ad. r tic 2_26VU
(3)
(4)
FOR DEVELOPERS IN OCEAN HAZARD AND ESTUARINE HAZARD AREAS:
I acknowledge that the land owner is aware that the proposed development is planned for an area which may be susceptible to
erosion and/or flooding. I acknowledge that the local permit officer has explained to me the particular hazard problems associ-
ated with this lot. This explanation was accompanied by recommendations concerning stabilization and floodproofing tech-
niques.
PERMISSION TO ENTER ON LAND:
I furtftertuire rertify that 1 gurt gkuthorizej-"rant-and do in fact grant permission to the local permit officer and his agents to
enter on the aforementioned lands in connection with evaluating information related to this permit application.
This application includes: general information (this form), a site drawing as described on the back of this application, the
ownership statement, the AEC hazard notice where necessary, a check for $100.00 made payable to the locality, and any infor-
mation as may be provided orally by the applicant. The details of the application as described by these sources are incorporated
without reference in any permit which may be issued. Deviation from these details will constitute a violation of any permit. Any
person developing in an AEC without permit is subject to civil, criminal and administrative action.
This the dayof 20
ti

AEC HAZARD NOTICE
Project Is In An: X— Ocean Erodible Area —High Hazard Flood Area_ Inlet Hazard Area
Date Lot Was Platted:
This notice is intended to make you, the applicant, aware
of the special risks and conditions associated with
development in this area, which is subject to natural
hazards such as storms, erosion and currents. The rules of
the Coastal Resources Commission require that you
receive an AEC Hazard Notice and acknowledge that
notice in writing before a permit for development can be
issued.
The Commission's rules on buildingstandards, oceanfront
setbacks and dune alteration aredesigned to minimize,but
not eliminate, property loss from hazards. By granting
permits, the Coastal Resources Commission does not
guarantee the safety of the development and assumes no
liability for future damage to the development.
The best available information, as accepted by the Coastal
Resources Commission, indicates that the annual ocean
erosion rate for the area where your property is located is
,A_ feet per year.
The rate was established by careful analysis of aerial
photographs of the coastline taken over the past 50 years.
Studies also indicate that the shoreline could move as
much as%0 feet landward in a major storm.
The flood waters in major storm arepredicted to be about
/a_/sfeet deep in this area.
Preferred oceanfront protection measures are beach
nourishment and relocation of threatened structures.
Hard erosion control structures such as bulkheads,
seawalls, revetments, groins, jetties and breakwaters are
prohibited. Temporary devices, including sand bags, may
be allowed under certain conditions.
This structure shall be relocated or dismantled within two
years of becoming imminently threatened.
The applicant must acknowledge this information and
requirements by signing this notice in the below space.
Without the proper signature, the application will not be
complete.
Applicant's Signature
Date
SPECIAL NOTE: This hazard notice is required for
development in areas subject to sudden and massive
storms and erosion. Permits issued for development in this
area expire on December 31 of the third year following the
year in which the permit was issued. Shortly before work
begins on the project site, the Local Permit Officer will
determine the vegetation line and setback distance at your
site. If thepropertyhas seen little change and theproposed
development can still me^t the setback requirement, the
LPO will inform you that you may begin work. Itis impor-
tant that you check with the LPO before the permit expires
for official approval to continue the work after the permit
has expired. Generally, if foundation pilings have been
placed and substantial progress is continuing, permit
renewal may not be necessary. If substantial progress has
not been made, the permit must be renewed and a new
setback line established. It is unlawful to continue work
after permit expiration without this approval.
For more information, contact:
Local Permit Officer
Ilal N. La�kfen Park 2>ovlevapr-8
Address -- I
NUM MM;VV -I
(gtol �5:g-a9�B
Phone
JUN 0 S 2004
CpAS A� MANAGG F
EMENT
Revised 11193

%ViaVA
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N3M300
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t

REQUIRED LAMA PERMIT NOTIFICATION
DATE: 5 M Dq
To: AI+1tr*1 Nam. S
This letter has been transmitted to you as required by CAMA to inform you that I (we) have
applied for a LAMA permit on property located at- )ylp C groy,ua &ad, Ave N
Carolina Beach, N.C. CAMA regulations require me (us) to notify you of my (our) intentions. I
(we) have enclosed a copy of my (our) permit application and plans of my (our) proposed
project No response within ten (10) days is the same as no objection when you have been
notified by Certified Mail.
If you have any comments relative to this proposal, please contact:
Jeremy Hardison, Local CAMA Permit Officer
1121 N. Lake Park Blvd.
Carolina Beach, NC 28428
[phone]
Sincerely,

REQIIIRED CAMA PERmrr NOTIFICATION
DATE: y1glal
To: booud Kowa\
Po Qrnt ►%,Q
✓UNaS ���
?p
CpgS7k 41ANq 4g
G�,yFNT
This letter has been transmitted to you as required by CAMA to inform you that I (we) have
applied for a CAMA permit on property located at 14►o Co.roCEEan CL( O av� a r1
Carolina Beach, N.C. CAMAregulatioas require me (us) to notify you of my (our) intentions. I
(we) have enclosed a copy of my (our) permit application and plans of my (our) proposed
project. No response within ten (10) days is the same as no objection when you have been
If you have any comments relative to this proposal, please contact:
Sincerely,
Jeremy Hardison, Local CAMA Permit Officer
1121 N. Lake Park Blvd.
Carolina Beach, NC 28428
[phone]
1-17 —_ --_

4/15/04
SETBACKS:
Front = 20'
Rear = 19
Side = 7.5'
50'
5�
I
I
I
3'
I
a
a
I
I
5'
I
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NI
I
I
I
�
SECOFLI.(I
Builders
1202 N. Lake Pads Blvd, Suite A
Carolina BmdL NC 2MW
Phone: [phone](46
Fax: (910) 45&7709
50'
JUN
Cpgs �l� �qq� 4
FNT
Harold Cooke
1410 Carolina Beach Ave N
WrNO. CITY
6 Carolina Beach
SCALE = 1:20
REV
AI'

Dennis Barbour
Mayor
Jack Lynch
Councilman
Joel Macon Jr.
Councilman
TOWN OF CAROLINA BEACH
1121 N. Lake Park Boulevard
Carolina Beach, North Carolina 28428
910 458 2986 / FAX [phone]
Public Notice
CAMA advertisement
Paz Efrid
Mayor Pro Tem
Gary Doetsch
Councilman
Calvin R. Peck,
Town Manager
S!041�
C
OgS�pC�M/0� 4
NOTICE
PP
CAMA MINOR EVELOPMENT PERMIT ��,�C'FM
Town of Carolina Beach FtiT
Pursuant to NCGS 113A-119(b), the Town of Carolina Beach, a locality authorized to issue
CAMA Permits in areas of environmental concern, hereby gives notice that on May 11, 2004_,
Secof Construction applied for a CAMA Permit to Demolish an existing single family structure
at: 1114 Carolina Beach Ave N. Carolina Beach, N.C. The application may be inspected at the
address listed below. Public comments received by May 24, 2004 will be considered. Later
comments will be accepted and considered up to the time of permit decision. Project
modifications may occur based on further review and comments. Notice of the permit decision in
this matter will be provided upon written request.
Jeremy W. Hardison
CAMA Local Permit Officer
Town of Carolina Beach
1121 N. Lake Park Blvd.
Carolina Beach, NC 28428
[phone]
( Please publish on May 14, 2004 )
Caption of Ad: CAMA
Mail Invoice and A, sdavits of Publication to Attention of Lynn Prusa, Town Clerk, Town of
Carolina Beach, 1121 N. Lake Park Blvd, Carolina Beach, NC 29428 Thank Youl)
1

Locality _I o W.n o`- (-r CAjo, 3 eu Permit NunibGQ0 04- as
Please /
permi Ocean Hazard Estuarine Shoreline _ORW Shoreline —Public Trust Shoreline _Other_
reque! (For official use only)
pl-nr( GENERAL INFORMATION
LAND OWNER
Name Ha r nW Cooke_
Address (oy l l,. Sob(, L.)
PHYf City Can& 6>ro State nrL
Zip =�N D Phone (`33b) 33+ - B6e0
­ 4UTHORIZED AGENT
If you Name SEeoF
Address lnk.A_ Park ►Q,\ rl
City Cato\ya t4ack —Scare. NG Zip _ 2 0L(29 Phone ` a - 5665'
LOCATION OF PROJECT: (Address, street name and/or directions to site. If nor nt, what is the name of
IFyou the adjacent waterbody?) . I410 Carols la %e Xe' Ave to : I, �&
DEVI DESCRIPTION OF PROJECT: (List all proposed construction and land
-_ SIZE OF TAT/PARCEL: l• ZtM
square feet . I tl acres
PROPOSED USE. Residential_X (Single-family X Multi -family _) Commerica ustrial _
Other _
NOT: TOTAL ENCLOSED FLOOR AREA OF A BUILDING IN THE OCEAN HAZARD AREA OF ENVI-
Have RONMENTAL CONCERN (AEQ: square feet (includes all floors and roof -covered decks)
• SIZE OF BUILDING FOOTPRINT AND OTHER IMPERVIOUS OR BUILT UPON SURFACES IN
THE COASTAL SHORELINE AREA OF ENVIRONMENTAL CONCERN (AEC): I boo sq. ft.
(Calculations include the area of the roof/drip line of all buildings, driveways, covered docks, concrete or masonry patios,
• etc that are within the applicable AEC. Attach your calculations with the project drawing.)
• Choose the AEC area that applies to your property-.
(1) within 75 feet of Normal High Water for the Estuarine Shoreline AEC
(2) within 575 fat of Normal High Water for the Estuarine Shoreline AEC, adjacent to Outstanding
Resource Waters
Si (3) within 30 feet of die Public Trust Shoreline AEC
$i 1Contactyonr ocal-PermirOfficerif you am notsure which -AEC applies to yourproperty.)
- STATE STORMWATER MANAGEMENT PERMIT. Is the project located in an area subject to a
State Stormwater Management Permit issued by the. N.C. Division of Water Quality?
YES_ NO
If Yes, fist the total built -upon area impervious surface allowed for your lot or parcel square feet

OTHER Ppcnnii S A4A1' BE REQUIRED; Th< activity you are planning may require permits other than the CAMA nninor
development permit- As a service we have compiled a list of the kinds of prnnits dh:,t might be required. \C4 suggcsr you cheek over the list
with your LPO to determine i(any of these apply nr your project: 'Zoning. IJninking \leaner \Y411, Septic (or other sanicaq'vt2stc
treatment system), Burning, Elrcuical, Plumbing, Heating and Air Conditioning, lusulation and Energy Conservation, FIA Certification,
Sand Dune, Sediment Control, Subdivision Approval, Mobile Home Par], Approval, Highway, Connection, and others.
STATEMENT OF OWNERSHIP.
I, the undersigned, an applicant for a CAMA in,
Person authorized to act as art agent nor development permit, being either the owner of property, in an AEC or a
listed as landowner on for purposes of applying for a CAMA minor development permit, certify drat the person
this for
has a significant interest in described as: (check one) the real property described therein- This interest can be
—X--an owner or record tide. Title is vested in
Page in the CountyRegistry of Deeds. see Deed Book
__an oxmer by virtue of inheritance. Applicant is an heir to the estate of
probate was in
County.
_if other interest, such as written contract or lease, explain below or use a separate sheer and attach to this application.
NOTIFICATION OF ADJACENT PROPERTY OWNERS,
I furthermore certify that the following L'
ACTUAL NOTICE to each of them inarm owners of properties adjoining this pry, . I a�i /k;,lb
(Name) concerning Y intent to develop this Property and to a �� t e n
P
(1) AI9�, Hwr.eg (Address) 9� X"
(2)iaac,c{ i[c 01 -- SDIB Ro d,l P 28 �i
(3) �o C0 c
(4)
FOR DEVELOPERS IN OCEAN HAZARD AND ESTU ARINE HAZARD
I acknowledge drat the !and owner is aware that the proposed development is AREAS:
erosion and/or flooding. I acknowledge P planned foz an area which may be susceptible to
ated with this lot. This expackn wl was accompanied a local by repermcommendations officer
has
ons explained
to me the particular hazard problems associ-
aiques. concerning stabilization and floodproofing tecb-
PERMISSION TO ENTER ON LAND:
I furthermore certify that I am authorized to grant and do in fact grant permission to the local permit offiicer and his agents to
enter on the aforementioned lands in connection with evaluating information related to this permit application.
This application state includes: general information (ere form), a site drawing as described on the back of this application, the
mationhip statement, the AEC hazard nonce where necessary a check for $100.00 made payable to the locality, and any infor-
mariou as may be provided orally by the applicant The derails of the a lication as _
_---- _pp described by these sources are incorporated
without reference in any permit which may be issued. Deviation from these details will constitute a violation of any pennie Any
Person developing in an AEC without permit is subject to civil, criminal and administrative anion.
This die 27dayof
20 Doi

AEC HAZARD NOTICE
Project Is In An: Ocean Erodible Area _ High Hazard Flood Area _ Inlet Hazard Area
Date Lot Was Platted:
This notice is intended to make you, the applicant, aware
of the special risks and conditions associated with
develohazard�suchtas stormin s eect to natural
rosion and currents. The rules of
the Coastal Resources Commission require that you
receive an AEC Hazard Notice and acknowledge that
notice in writing before a permit for development can be
issued.
The Commission's rules on buildingstandards, oceanfront
setbacksand dune alteration aredesigned to.mulimize,but
not eliminate, property loss from hazards. By granting
permits, the Coastal Resources Commission does not
guarantee the safety of the develo ment and assumes no
liability for future damage to the development:
The bestavailable information, as accepted by the Coastal
Resources Commission, indicates that the annual ocean
erosion rate for the area inhere your property is located is
feet per year.
The rate was established by careful analysis of aerial
photographs of the coastline taken over the past 50 years.
Studies -Aso indicate- that the shoreline could move as
muchas-feet landward in a major storm.
The flood waters ma majorstorm arepredicted to beabout
et deep in this;a;ea,.
Preferred oceanfront protection ;aeasures are beach
nourishment ,and relucation.4f threatened structures.
Hard erosion control structures such as bulkheads,
seawalls, revetments, groins, jetties and breakwaters we
brohfbited..Temporary-devices, including sand bags, may
e allowed under certain condih
development in E: This areas subjectd notice is re uired o sudden and massive
storms and erosion. Permits issued for develo mentinthis
area expire on December 31 of the third year following the
gear in which the permit was issued. Shortly before work
begins on the project site, the Local Permit Officer will
determine the vegetation lineand setback distance at your
site. If the propertyliasseenlittlechangeand theproposed
development can still nie�t the setback requirement, the
LPO willinform you that you mg begin work. Itisimpor-
tantthat you check with the LPO before the permit expires
for official approval to continue the work after the permit
has expired. Generally, if foundation pilings have been
placed and substantial progress is continuing, permit
renewal not been ma e, the not be necessary.
yust be renewestantial d anProgress new
setback line established. It is unlawful to continue work
after permit expiration without this approval.
For more information, contact
Loc rmIOflicer
Qrra ri.8( �R4a8
Address
Thud) n-F C'nrla�(
Localay
ons.
This structure shall berelocated,ordismantled within two %tnl 'q5>g-a9'7g
years of becoming imminently threatened, z` �Ph°ne f •--,.
The applicant must acknowledge this information and
requirements by signing this notice in the below space.
Without the proper signature
complete. , the application willnot be
Applicants Signature
_ s/zs/0'1
Date
4!
....c.. N
gtig11�MF� .. .
T
_ . Revised 14193

REQUIRED CAMA PERMIT NOTIFICATION
DATE:
To: T'aWd hgnrlaj
CarOI-ItA 119d - NC ZSg7-S
This letter has been transmitted to you as required by CAMA to inform you that I (we) have
applied for a CAMA permit on property located at �yto Cnrol'�rxi Fjtacl� A.,c IJ
Carolina Beach, N.C. CAMA regulations require me (us) to notify you of my (our) intentions. I
(we) have enclosed a copy of my (our) permit application and plans of my (our) proposed
project No response within ten (10) days is the same as no objection when you have been
notified by Certified Mail.
If you have any comments relative to this proposal, please contact:
Jeremy Hardison, Local CAMA Permit O6Ocer ✓GN
1121 N. Lake Park Blvd.
Carolina Beach, NC 28428 9`r�o�L "P
[phone] _
0
�� 2j`r�py
Sincerely, 9� �

REQUMED CAMA PERMIT NOTIFICATION
DATE: 5.1a lay
This letter has been transmitted to you as required by CAMA to inform you that I (we) have
applied for a CAMA permit on property located at
141p C4rp1',wla doncV_ _ M N
Carolina Beach, N.C. CAMA regulations require me (us) to notify you of my (our) intentions. I
(we) have enclosed a copy of my (our) permit application and plans of my (our) proposed
project. No response within ten (10) days is the same as no objection when you have been
notified by Certified Mail.
If you have any comments relative to this proposal, please contact:
Jeremy Hardison, Local CAMA Permit Office0O e�� d✓ flr
1121 N. Lake Park Blvd.
Carolina Beach, NC 28428 T9� S�� 904PR
[phone]
Sincerely,

4/15/04
SETBACKS:
Front = 20'
Rear = 19
Side = 7.5'
50'
I
42'
3'
I
O
-
a
i�
I
5'
I I
OI
NI
I I
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SECOF►.I.0
Builders
Developers
I=N. lake Pack Blvd, Suite A
CamBna Beach, NC 78M
Phone: [phone]
Fax; [phone]
50'
Harold Cooke
1410 Carolina Beach Ave N
LOT NO. 5 I MY
CaroBna Beach
RE" I Al'
(�x15 �,N° 0)ePM ng

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Postage
L2.39
Certified Fee
Retum Receipt Fee
31.75
(Endorsement Required)
Restricted Delivery Fee
$jJ,l)fj
(Endorsement Required)
1428
Q2 Postmark
Here
$ l4.42 95/177f2004
Total Postage 8 Fees
M1
CAROLINA BEACH NC, 28428
Er
Ill
O
Postage
$ $077
Cedi ied Fee
$2.30
0428
t7
R
Receipt Fee
Return IEntlorsement Required)
i12 PO$Imetk
Here
$1.75
0
p
Restricted Delivery Fee
(Entlaement Required)
$ft.00
1-3
M1
Total Postage a Fee.
$ $4.42
L5/107/2004
p
Sent T
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Sfree! f No.; or Pour Nc.
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...............
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■ Complete items 1, 2, and 3. Also complete A
item 4 if Restricted Delivery is desired.
■ Prim your name and address on the reverse
so that we can return the card to you. B.
■ Attach this card to the back of the mailpirace,
or on the front if space permits.
1. Article Addressed to:
A\TI Cc S
❑ Agent
by (Printed Name) I C.
Is delivery address differerH from item 17
it YES, enter delivery address below: ❑
3. Service Type
H Certified Mail
❑ Express Mail
/❑ Registered
❑ Return Receipt for Merchandis
❑ Insured Mail
❑ C.O.D.
4. Restricted Delivery? (Extra Fee) ❑ yes
2. Article Number
(Transfer from service label) tLtp5 4oz-4
PS Form 3811, August 2001 Domestic Return Recelpt 2ACPPo-0.4P-40E

UNITED STATES POSTAL SERVICL,✓ FkstLlass Mail
tage& Fees -Paid
ZETIN
:�. PM c+ r•tlor+t ���
• Sender. Please pti�it °ftaiyle, address,
Srtor

Complete items 1, 2, and 3. Also complete A. Signature
item 4 if Restricted Delivery is desired. ❑
1 Print your name and address on the reverse X C4
sib that we can return the card to you. R. Reoeivad by (Printed Name) C. Date
Attach this card to the back of the mailpiece, C
or on the front if space permits.'K-
I. Article Addressed to:
b:tuod knVY'a1
Po bw ►ISbo
C4cov r.xx� �C 28�k W
D. Is delivery address different from item 19 Ye.
d YES, enter delivery address below: ❑ No
3. Service Type
❑ Certified Mail
❑ Express Mail
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