69-17 Singleton, Tom

Locality i Grir-6.1,2,--1— Permit Number t,
Ocean. Hazard Estuarine Shoreline ORW Shoreline Public Trust Shoreline Other
(For official use only)
GENERAL INFORMATION
LAND OWNER-MAILING ADDRESS
Name W OR.V 4 Lt.G 1"0 Nt 't'6 rJ
Addfess I `(b 3 l:#w 4 "2-q-
City Neupoll.T State t4 G- Zip Z.$ 1O Phone Z"S' 2- ` 2-4 I-0' d.-
Email
AUTHORIZED AGENT
Name P —1 6 = GkNr 0(4 L h,t,6 - 412 .I6, '1
Address 1 - 4, MG(.e 4-440
city C4Pe C` }.R-Tc to State T-kr--- Zip18S '1+ Phone LSZ-3413•L!Zl
Email 'i S Ltt.„c•` �4- a t-4 •.t
LOCATION OF PROJECT: (Address,street name and/or directions to site;name of the adjacent waterbody.)
1-N10 3 kw 44 Z-+ -'71►n�,., , Luh►revts Ebb E. e-1/ P, t-t tPL.Ikreit. a F .Fa DC v6 0.-sp
DESCRIPTION OF PROJECT: (List all proposed construction and land disturbance.) Li.a ST.4 L L A rot,. 15o I
of LI-. Fe c e ..' ro "-
SIZE OF LOT/PARCEL: ! square feet 14, ( acres
PROPOSED USE: Residential (Single-family I J Multi-family ) Commercial/Industrial El Other ErRit/ fit,
COMPLETE EITHER(I)OR(2)BELOW(Contact your Local Permit Officer if you are not sure which AEC applies
to your property):
(1) OCEAN HAZARD AECs:TOTAL FLOOR AREA OF PROPOSED STRUCTURE: s-tfA square feet(includes
air conditioned living space,parking elevated above ground level,non-conditioned space elevated above ground level but
excluding non-load-bearing attic space)
(2) COASTAL SHORELINE AECs: SIZE OF BUILDING FOOTPRINT AND OTHER IMPERVIOUS OR BUILT
UPON SURFACES: WA square feet(includes the area of the foundation of all buildings,driveways,covered decks,
concrete or masonry patios,etc.that are within the applicable AEC.Attach your calculations with the project drawing.)
STATE STORMWATER MANAGEMENT PERMIT: Is the project located in an area subject to a State
Stormwater Management Permit issued by the NC Division of Energy,Mineral and Land Resources(DEMLR)?
YES NO
If yes,list the total built upon area/impervious surface allowed for your lot or parcel: r4/4 __ square feet.

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ADJACENT RIPARIAN" PROPERTY OWNER
STATEMENT FOR CAIVIA MINOR PERMITS
herot:,r, cr (8)c'(2.4 - 1e4c&-bz, Rio
(Name of Property Owner
Address, Lot, Block, Road, )
60bUg tAt)A.),00 in AiXev'Ll AJ11 C
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the attacht4 app(ica.iior and project drirokoevh.;), ti;e
'hat l ).!en wia. I have no objection V his w.f.ipo.sal
AND DRAWING OF PROPOSED DEVELOPMENT ATTACHED}
SIgnatute
Print or Tyne Name
Te"lepi'mne Number
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U.S. Postal Service,,
to CERTIFIED MAIL RECEIPT
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Total Postage&Fees
12/21/2017
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PS Form 3800,August 200c 1 c -857 0
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� CERTIFIED MAIL-, RECEIPT
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Total Postage&Fees
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ON state,2eQ+4 2-6 S-1 0
PS Form 3800,August 200&' See Reverse for Instructions

• I .
OTHER PERMITS MAY BE REQUIRED:The activity you are planning may require permits other than the CAMA
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
Certification,Sand Dune, Sediment Control, Subdivision Approval, Mobile Home Park Approval,Highway Connection,and
others. Check with your Local Permit Officer for more 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
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)
f
Jan owner or record title,Title is vested in name of E4)6-1 t t t.+G-
see Deed Book 1440 page 3z4 in the CALartg -1. County Registry of Deeds.
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&attach to this application.
NOTIFICATION OF ADJACENT RIPARIAN 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) C(704.brui P. LetJt, 14 ( fiw_i 2 _ Nt:t.JPaia t 1.4c.. 26 5 Zo
(2) IiA2&LG• t-IAv,U `2.2.` W41, Q041) N�+.-aJ, ..rr-tc. 'z48570
(3)
(4)
ACKNOWLEDGEMENTS:
I,the undersigned,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 particu-
lar hazard problems associated with this lot.This explanation was accompanied by recommendations concerning stabiliza-
tion and floodproofing techniques.
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.
/ This the Z'' ._. day of cr( Qiab 20 t
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Lando . +r person aut prized act as his/her agent for purpose of filing a CAMA permit application
This application includ• :general information(this form), a site drawing as described on the back of this application, the
ownership statement, the Ocean Hazard AEC Notice where necessary; a check for$100.00 made payable to the locality, and
any information 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.