WB_04-43_Liccione

Town of Wrightsville Beach 1Ty 0-EI ip,1v� D W604 - 43
Local Government Permit Number
NOV 15 2004
DIVISION OF CAMA
COASTAL MAN PiWTDEVELOPMENT
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 environmental concern pursuant to Section 113A-118 of the
General Statutes, 'Coastal Area Management'
Issued to Richard Liccione, authorizing development in Wrightsville Beach at 619 South Lumina Avenue as requested in
the pemlitteeIs application, dated October 13, 2004. This permit, issued on November 12, 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 terns may subject permittee to a fine, imprisonment or civil action, or
may cause the permit to be null and void.
Alteration to existing Duplex
1) The structure shall comply with the North Carolina Building Code, including the Coastal and Flood Plain Construction
Standards, Chapter 37, Volume 1 or Chapter 41, Volume 7, and the National Flood Insurance Program. If any
provisions of the building code or a flood damage prevention ordinance is inconsistent with any of the following AEC
standards the more restrictive provision shall control.
2) The structure must not extend beyond the toe of the frontal dune.
3) The structure must be elevated on pilings with a diameter of at least 8 inches and bottom of lower structural members
excluding piles must meet the 100-year flood level elevation of (14 or 15) feet.
4) All pilings within the Ocean Hazard Area shall have a tip penetration of at least five feet (5) below mean sea level or
sixteen feet (16) below average original grade, whichever is least.
5) Dune disturbances will be allowed only to the extent necessary for development and if the dune's protective valve is not
weakened or reduced. Disturbed areas will be immediately stabilized.
6) The permit may be renewed for one (1) year if requested before the expiration date.
7) The permittee is required to contact the Local Permit Officer shortly before he plans to begin construction to arrange a
setback measurement which will be effective for sixty (60) days barring a major shoreline change. Construction must
begin within sixth (60) days of the determination or the measurement is void and must be redone.
8) Sand used to strengthen dunes must be brought in from an outside source and must be of the same nature as the sand
in the area in which it is to be placed. No sand is to be removed from the lot.
9) Sand held in storage in any dune, other than frontal or primary dunes, may be moved laterally in order to strengthen
existing primary or frontal dunes if the work would enhance the protection to the proposed development activity and the
sand is immediately stabilized.
10) All development must be consistent with all applicable Federal, State and Local standards.

PAGE
Conditions Continued
11) Any structure authorized by this permit shall be relocated or dismantled when it becomes imminently threatened by
changes in shoreline configuration. The structure(s) shall be relocated or dismantled within two (2) years of the time
when it becomes imminently threatened, and in any case, upon its collapse or subsidence. However, if natural
shoreline recovery or beach re -nourishment takes place within two (2) years of the time the structure becomes
imminently threatened, so that the structure is no longer imminently threatened, then it need not be relocated or
dismantled at that time. The condition shall not affect the permit holder's right to seek authorization of temporary
protective measures allowed under CRC Rules.
12) Proposal shall comply with provisions of Wrightsville Beach Access System and Structures regulations, 152.095
through 152.104 and Sand Dunes 152.115 through 152.122.
This permit action may be appealed by the permdee or other
qualified persons within twenty (20) days of issuing date. 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 site and accessible to the permit
officer when the project is inspected for compliance.
Any maintenance work or project modifications not covered under
this permit requires further written permit approval.
All work must cease when this permit expires on December 31,
2007.
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.
Local €rmit Officer (Signature)
Jon W Giles Jr
The Town of Wrightsville Beach
321 Causeway Drive
Wrightsville Beach, North Carolina 28480
U,
Permittee
(signature required if special conditions above apply to permit)

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APPLICATION FOR
R
`T
PERMIT
North Carolina General Assembly, passed the Coastal Area
,Act and set the stage for guiding development in fragile ,
ie areas that border the state's sounds and oceanfront Along '
g special care bythose who.build and develop, the General
ctedahe Coastal Resources Commission (CRC) to imp
le
ment clear regulations that rnimmize the burden on the applicant A.: }
This application for a minor develop -mint permit under'... is part
a of the Commission sreffort to meet the spirit and intent of the General
Assembly. It has beeA designed to be straightforward and require no
Vmore time or effort necessary froiti the applicant. 2Please go over this':','
folder with the hocal Peimit Officer (LPO) for the locality in whichyou
plan to buildio U c�' n thatyou understand whatinformation
she needs.
Under CAM, regulations, the minor permit is to be issued within 25
mr zY A: o
days once a completexptz anon is in hand. Often less time is needed if
the project is simple The process generally takes about 18 days. You
l ry can speed the approval process by making certain that your application
its complete and signed,'that your drawing meets the specifications given
inside and that your application fee is attached.
Other'permits are sometimes required for development in the coastal
area. While these are not CAMA-related, we urge you to check with the
1 Local Permit Officer to determine which of these you may need. A
listing is included on page 2 of this folder.
` aWe'appreciate your cooperation with the North Carolina Coastal Man-
'
gement Program aril your willingness to build in away that protects
heresources of oiii beaiitifu( and productive coast
J.
Coastal Resources Commission
R Division of Coastal Management
iF
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Locality' c k+s J r ILL Per Number W 0 t3
Ocean Hazard Estuarine Shoreline ORW Shoreline _Public Trust Shoreline Other'_
(For official use only) RECEEVE
GENERAL INFORMATION
LAND OWNER OCT 18 P004
�p DIVISION OF
Name Iltc�nwrol aHok �Ayt L_icaiotne, COASTAL MANA(`C!tA
Address Hy ROWnel Wkl �.
City keNv%eloy% State M.a. Zip 0744e)S Phone0223 L192-8367
AUTHORIZED AGENT
Name�tik eiwrtti�eo THc
Address (0131 Oleander 7rx.
City W_ Z1t^+%Aa�nin State A- i' . Zip AS'403 Phone 3e15 - 6090
I
LOCATION OF PROJECT: (Address, street name and/or directions to site. If not oceanfront, what is the name of
the adjacentwaterbody?) (olol SoUAVt L_l.mut a, Am, anA I
DESCRIPTION OF PROJECT: (List all proposed construction and land disturbance.)
SIZE OF LOT/PARCEL: 2. 0a5 square feet acres
PROPOSED USE: Residential (Single-family _ Multi -family v_ ) Commerical/Industrial
Other
TOTAL ENCLOSED FLOOR AREA OF A BUILDING IN THE OCEAN HAZARD AREA OF ENVI-
RONMENTAL CONCERN (AEC): 3,'7 9 L( 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): Q, A 35 sq. &
(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
(3) within 30 feet of the Public Trust Shoreline AEC
(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_�
If yes, list the total built -upon area/impervious surface allowed for your lot or parcel. square feet.

ETHER PERMITS MAY BE REQUIRED: The activity you are planning may require permits other than the CAMA minor y
development permit. Asa service we have compiled a list of the kinds of permits that might be required. We u t you check over the list b
with your LPO to determine ifany of these apply to your project: Zoning, Drinking Water Well, Septic Tank t
treatment system), Building, Electrical, Plumbing, Heating and Air Conditioning, Insulation and Energy Co e Sand Dune, Sediment Control, Subdivision Approval, Mobile Home Park Approval, Highway, Connection, others.. 'E
OCT 18
2004 z
STATEMENT OF OWNERSHIP: DIVISION
CO�gSTAL 1�1� OF
I, the undersigned, an applicant for a CAMA minor development permit, being either the owner o properry i �66:MENT
person authorized to act as an agent for purposes of applying for a CAMA minor development permit, certify that the person
listed as landowner on this application has a significant interest in the real property described therein. This interest can be
described as: (check one)
✓ an owner or record title. Title is vested in 'R,i6gd+Sea%Ltca,e e see Deed Book 144 ha 0'
page 156e in the _ &w NA%ovef County Registry of Deeds. Z
_an owner 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 sheet and attach 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)
(I) McA%E.iTC 1k4w,I IM York_ k _?MsbmrA^ -PA I5938
(2)
(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 .Vrith this lot. This explanation was accompanied by recommendations concerning stabilization and floodproofing tech-
niques.
PERMISSION TO ENTER ON LAND:
I furthermore certify that I am authorized to grant 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 theei70 day of rJC %n�E 20 Oq
Landowner or person authorized to as as his agent for purpose of filing a CANIA permit application.
s

SITE DRAWING/APPLICATION CHECKLIST
Please make sure your site drawing includes the following information required for a CAMA minor develop-
ment permit. The drawing may be simple and not necessarily to scale. The Local Permit Officer will help you,
if requested.
PHYSICAL DIMENSIONS
_ label roads
_ label highways right of ways
label local setback lines
_ label any and all structures and driveways currently existing on property
PHYSICAL CHARACTERISTICS
draw and label mean high water mark
draw location of on -site wastewater system
If you will be working in the ocean hazard area:
draw and label dune ridges (note height) .
draw and label toe of dune
_ identify and locate first line of stable vegetation
draw and label setback line under CAMA
draw and label topographical features (optional)
If you will be working in an estuarine shoreline area:
draw and label landward limit of AEC
describe terrain (slope)
DEVELOPMENT PLANS
�C��IvED
OCT 18 2004
COASTAL DIVISION OF
MANAGEMENT
draw and label areas that will be disturbed
if a house is to be placed on lot, describe location of house
note size of pilingg and depth to be placed in ground
draw and label A areas to be paved or graveled
_ describe composition of surface
note and list fully all trees and vegetation to be removed or relocated
show landscaping
NOTE TO APPLICANT
Have you: '
*completed all blanks and / or indicated if not applicable?
*notified and listed adjacent property owners?
*included your site drawing?
*signed both application and statement of ownership?
*enclosed the $100.00 fee?
*completed an AEC Hazard Notice, if necessary?
FOR STAFF USE
Site Notice Posted Final Inspection Fee Received
Site Inspections
Date of Action: Issued Exempted Denied Appeal Deadline (20 days)

Receipt for
Certified Mail
Staple Here
9417 aooy
DateSeav�e�-%e R4vrts
Adjacent Property Owner
Ita y0(V,S�A«e,-JDC OCT 18 2004
Address DIVISION OF
PAI �S01A(A., TA 15A38 COASTAL MANAGEMENT
City, State, Zip Odde
Dear Adjacent Property Owner:
This letter is to inform you that I,
IZtc�a(ol. Ltec %ohe- have applied for a CAMA
Property Owner
permit on my property at
Wrightsville Beach, North Carolina. CAMA regulations require that I notify you of my
proposed development. Enclosed is a copy of the proposed project plan and my
permit application.
Comments will be considered up until the time of issuance of the permit. If you have any
comments or questions regarding my proposed project, please contact:
• Town of Wrightsville Beach, Planning and Parks Department, CAMA Local Permit
Officer, 321 Causeway Drive, Wrightsville Beach, North Carolina, 28480
Phone [phone]
Sincerely,
CA
Name
10
have no objections to the
prop6Jed project as represented in the attached plan and application. This signature once
presented to the Planning and Parks Department will show no objection and my expedite
the CAMA permit.

Date: October 13, 2004
Memo To: Classified Department
From: Jon W Giles Jr
Subject: CAMA Permit Application Notice
E "z v Cd
OCT 18 2004
N OF
COASTAL IIMAONAGEMENT
Please print the following in the legal notice section of the Star News as soon as possible. We will
need an affidavit of publication sent to the Planning and Inspections Department, 321 Causeway
Drive, care of nrj attention. Account 256-7900.
Thank you for your assistance.
NOTICE OF FILING
OF APPLICATION FOR
CAMA MINOR DEVELOPMENT PERMIT
Pursuant to NCGS 113A 119(b), the Town of Wrightsville Beach, a locality authorized to issue
CAMA permits in areas of environmental concern hereby gives notice that on October 12, 2004,
Richard Liccione of 619 S. Lumina Ave., Wrightsville Beach, NC 29480 applied for a CAMA
Permit to alter existing Duplex and all associated ground disturbance. The application may be
inspected at the address below. Public comments received within 15 days of this publication will
be considered.
Jon W Giles
CAMA Local Permit Officer for
Town of Wrightsville Beach
321 Causeway Drive
Wrightsville Beach, N. C. 2848C
910-509-5019 ex 204

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OCT 18 P004
This letter is to inform you that I, DIVISION OF
ikiL\na(d Ltbctone ,haveQP9"f%k @@ MAGEMENT
Property Owner
permit on my property at 61°1 SowA\ LtAr, r'a At4e
S"c Address
Wrightsville Beach, North Carolina. CAMA regulations require that I notify you of my
proposed development. Enclosed is a copy of the proposed project plan and my
permit application.
Comments will be considered up until the time of issuance of the permit. If you have any
comments or questions regarding my proposed project, please contact:
• Town of Wrightsville Beach, Planning and Parks Department, CAMA Local Permit
Officer, 321 Causeway Drive, Wrightsville Beach, North Carolina, 28480
Phone [phone]
Sincerely,
aA N >•L %.a((e�W,TNe
Name
Wt (5la•ti.1,.Tr 1.r,1M ":.o�ew r1.e.aA�fo3
Address
0)101 3°t"5 - O09 0
Telephone Ntunllxr
I, , have no objections to the
proposed project as represented in the attached plan and application. This signature once
presented to the Planning and Parks Department will show no objection and my expedite
the CAMA permit.

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Adjacent Property Otwer
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OCT 18 2004
This letter is to inform you that I, DIVISION F
RtbW.rd Ltt'6o%e_ hav�igc'f ran¢ �EMENT
Property Owner
permit on my property at (,19 SoyVAt LL im ;,n Ave
Street Address
Wrightsville Beach, North Carolina. CAMA regulations require that I notify you of my
proposed development. Enclosed is a copy of the proposed project plan and my
permit application.
Comments will be considered up until the time of issuance of the permit. If you have any
comments or questions regarding my proposed project, please contact:
• Town of Wrightsville Beach, Planning and Parks Department, CAMA Local Permit
Officer, 321 Causeway Drive, Wrightsville Beach, North Carolina, 28480
Phone [phone]
Sincerely,
JO��+, IA:� 4t 1 ,jV .QtfBT7 IUEV., LInG.
Natne
1, , have no objections to the
proposed project as represented in the attached plan and application. This signature once
presented to the Planning and Parks Department will show no objection and my expedite
the CAMA permit.

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Adjacent Property Owner
Address
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City, State, Zip Odde
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OCT 18 2004
Postrnark
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This letter is to inform you that I, qq DIVISION OF
'RtCNQ(d Ltccta�e , have pplie�ba,�i'EMENT
Property Owner
permit on my property at 61 Ct 50.k\n Lt.vvntnw Acre
Wrightsville Beach, North Carolina. CAMA regulations require that I notify you of my
proposed development. Enclosed is a copy or the proposed project plan and my
permit application.
Comments will be considered up until the time of issuance of the permit. If you have any
comments or questions regarding my proposed project, please contact:
• Town of Wrightsville Beach, Planning and Parks Department, CAMA Local Permit
Officer, 321 Causeway Drive, Wrightsville Beach, North Carolina, 28480
Phone [phone]
Sincerely,
UDlntn WVI• t�5 a+ I�l ti;U 0'((6,W DP_J- 1lkG.
Name
1, , have no objections to the
proposed project as represented in the attached plan and application. This signature once
presented to the Planning and Parks Department will show no objection and my expedite
the CAMA permit.

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Dear Adjacent Property Owner:
This letter is to inform you that I,
'Rr&l ord LrLC10�2 , nav teaaova»VOWOF
Property Owner MASTAL MANAGEMENT
permit on my property at 619 SoLAA LVWMr AAVC.
. street Address
Wrightsville Beach, North Carolina. CAMA regulations require that I notify you of my
` • 75 7 Hare
proposed development. Enclosed is a copy of the proposed project plan and my
permit application.
Comments will be considered up until the time of issuance of the permit. If you have any
comments or questions regarding my proposed project, please contact:
• Town of Wrightsville Beach, Planning and Parks Department, CAMA Local Permit
Officer, 321 Causeway Drive, Wrightsville Beach, North Carolina, 28480
Phone [phone]
Sincerely,
Name
�131 Olea�olerl�r .1-Iw„�s�ke rii C o29(iO3
Address
I, , have no objections to the
proposed project as represented in the attached plan and application. This signature once
presented to the Planning and Parks Department will show no objection and my expedite
the CAMA permit.

BEFORE YOU BUILD OCT 18 2004
Setting Back for Safety: A Guide to Wise Development Along Ell&CRIawapit
COASTALMANAGEMENT
When you build along the oceanfront you take a calculated
risk. Natural forces of water and wind collide with tons of
force, even -on calm days.
Man-made structures cannot be guaranteed to survive the
force of a hurricane. Long-term erosion (or barrier island
migration) may take from two to ten feet of the beach each
year and, sooner or later, will threaten oceanfront struc-
tures. These are the facts of life for oceanfront property
owners.
The Coastal Resources Commission (CRC) has adopted
rules for building along the oceanfront. The rules are in-
tended to avoid an unreasonable risk to life and property
and to limit public and private losses from storms and
long-term erosion. These rules lessen but do not eliminate
the element of risk in oceanfront development.
As you consider building along the oceanfront, the CRC
wants you to understand the rules and the risks. With this
knowledge you can make a more informed decision about
where and how to build in the coastal area.
The Rules
When you build along the oceanfront, coastal manage-
ment rules require that the structure be sited to fit safely
into the beach environment.
Structures along the oceanfront must be behind the frontal
dune, landward of the crest of the primary dune and set
back from the first line of natural stable vegetation a dis-
tance equal to 30 times the annual erosion rate (a minimum
of 60 feet). Large structures (multi-familyresidential struc-
tures greater than 5,000 square feet and non-residential
structures greater than 5,000 square feet) must be set back
from the first line of natural stable vegetation a distance
equal to 60 times the annual erosion rate or 120 feet,
I�p
SETBACK' SETBACK
FIRST LINE OF
10 a IS—
STABLE
ALI 30 x ANNUAL
I
NATURAL
fT
000
AVERAGE AVERAGE
IEROSION I EROSION I
VEGETATION
I RATE
000
IRATE
I
I I I
I
(LARGE
(SMALL ' I
STRUCTURES)
I STRUCTURES)
PERMITTED
STRUCTURE;
ADEQUATE
SETBACK
whichever is greater. If the erosion rate is greater than 3.5
feet/year, the setback is 30 times the erosion rate plus 105
feet.
The Reasons
The beachfront is an ever -changing landform. The beach
and the dunes are natural "shock absorbers", taking the
beatings of the winds and waves and protecting the inland
areas. By setting back 30 or 60 times the annual long-term
erosion rate, you have a good chance of enjoying the full
life of the structure. At first, it seems very inviting to build
your dream house as close to the beach as possible, but in
five years you could find the dream has become a
nightmare as high tides and storm tides threaten your
investment.
The Exception
The Coastal Resources Commission recognized that these
rules, initially passed in June of 1979, might prove a
hardship for some property owners. Therefore, they estab-
lished an exception for lots which cannot meet the setback
requirement. The exception allows buildings in front of the
setback line if the following conditions apply:
(1) the lot must have been platted as of June 1,1979, and
not capable of being enlarged by combining with adjoining
land under the same ownership, (2) development must be
as far back on the property as possible and in no case less
than 60 feet landward of the vegetation line, (3) no
development can take place on the frontal dune (4) special
construction standards on piling depth and square foo tage
must be met and (5) all other CAMA, state and local
regulations must be met.
The exception is not available in the Inlet Hazard Area.
To determine eligibility for the exception, the Local Permit
Officer will make these measurements and observations:
required setback from vegetation line
exception setback (maximum feasible)
rear property line setback
max. allowable square footage on lowest floor
lot area as calculated from vegetation line
piling length needed to extend 4 feet below MSL
PRE -PERMIT STRUCTURE; INADEQUATE SETBACK
PRE -STORM BEACH PROFILE
_� POST -STORM BEACH PROFILE
ONE YEAR AFTER STORM/BEACH REBUILDING
After the storm, the house on the dune will begone. The other house has a much better chance of survival.

AEC HAZARD NOTICE
Project Is In An: 4— Ocean Erodible Area_ High Hazard Flood Area Inlet Hazard Area
Date Lot Was Platted: Ave,; ma
This notice is intended to make you, the applicant, aware
of the special risks and conditions associated with
development to 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 onbuilding standards, 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 develo ent 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
- 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 I le feet landward in a major storm.
The flood waters in a major storm are predicted to be about
Ik feet 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,Ogproper signature, the _application will not be
SPECIAL NOTE: This hazard notice is required for
development in areas subject to sudden and massive
storms and erosion. Permits issued for development inthis
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 meet the setback requirement, the
LPO will inform you that you may begin work. It is 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
3111 C4U.S- A `i b Y-I v,-e—
Address
Locality
ctt
Phone
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Applicant's Signature ROCT 1 8 2004
X9ZQ� DIVISION OF
Date COASTAL MANAGEMENT
Revised 11193

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