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HomeMy WebLinkAbout15527_NC DOT & TURNER, RANDALL_19960710ZI)o z] Z7//C/rf/OC�J� s CAMA AND DREDGE AND FILL p 5) 0�.527-e, U GENERAL SEP 1 1 t99i6 PERMIT as authorized by the State of North Carolinaw��M��1�,� Department of Environment, Health, and Natural Resources and the Coastal Resources Commission j in an area of environmental concern pursuant to 15A NCAC'� Applicant Name lVebur 2,c,A 4,gxlz-),4 c T r/RNc%r Phone Number Address 0• x, l as — City e/STY State PVC. zip d 77041 /;10S_ Project Location (County, State Road, Water Body, etc.) SA, 1-dAl t /'ce/N, cZ -n_. ,U ^A"l./ca scwo �s�-' oll f g Crj�=t/r D'r�l�✓r�s 5car,0/11. O/V Gcrr4co&e Type of Project Activity �50�.•9n/ 7/MdLc/2 �3lP.I,b c5 � � tq''�y� ' Gf/�'/)� �' f �'�` % ' L ci✓�i � /1i/f%/N7c�i*�A•ti'e'�" ,�' Y•f•9 t/-Q/? U.N G'�` l�4NAL e/ivDr'�P .�1liDG� f1"4 /N_s'.7;ge eATia,✓ -F A TF.��'o,PA.t'Y .�,E"�ES '�•'t�•e �9C/�J�4Y AU/C.✓nrCa raAfsiT1UC oAJ �P mlt /✓'T, 7 PROJECT DESCRIPTION SKETCH (SCALE: ) Pier (dock) length Groin length number Bulkhead length max. distance offshore Basin, channel dimensions �� r i S9 "4 x � 30 n+ x - s� cubic yards 3U(c Boat ramp dimensions Other rFMf' , Dt5S OF 14 ,4N*w4G K Wel r This permit is subject to compliance with this application, site drawing and attached general and specific conditions. AnyI',�/! C �''�/ violation of these terms may subject the permittee to a fine, X !U/ applicant's signature imprisonment or civil action; and may cause the permit to be- come null and void. /r e J 1!�;If A— 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 1) this pro- ject is consistent with the local land use plan and all local ordinances, and 2) a written statement has been obtained from adjacent riparian landowners certifying that they have no objections to the proposed work. emit otticer's signature y .T3P_ issuing date expiratio ate attachments 711. �,_?Uo In issuing this permit the State of North Carolina certifies that v� t,/ r� this project is consistent with the North Carolina Coastal application fee J-0 /Jc-/CrC Management Program. Form D&-MP-1 APPLICATION (To be completed by all applicants) 1. APPLICANT b. City, town, community or landmark Ocracoke a. Landowner: Name N. C. Department of Transportation Address P.O. Box 25201 City Raleigh State N.0 Zip 27611-5201 Day Phone (919) 733-3141 Fax (919) 733-9794 b. Authorized Agent: Name M. Randall Turner Environmental Officer Address P.O. Box 1405 City Elizabeth Citv State N.C. Zip 27906-1405 Day Phone (919t 331-4737 Fax _(919) 331-4739 c. Project name (if any) Oyster Creek Bridge 9 3 VOTE: Permit will be issued in name of landowner(s), andior project name. 2. LOCATION OF PROPOSED PROJECT a. County Hvde c. Street address or secondary road number confluence of SR 1362 and Bridge Road d. Is proposed work within city limits or planning jurisdiction? X Yes No e. Name of body of water nearest project (e.g. river, creek, sound, bay) Tributary canal to Oyster Creek 3. DESCRIPTION AND PLANNED USE OF PROPOSED PROJECT a. List all development activities you propose (e.g. building a home, motel, marina, bulkhead, pier, and excavation and/or filling activities. Removal of existing— bridge including_ support piers. construction of new timber bridle, fill will be placed on approaches and side slopes to dress and stabilize slopes and to accommodate new deck elev b. Is the proposed activity maintenance of an existinsi project, new work, or both? both c. Will the project be for public_ private or commercial use? public d. Give a brief description of purpose, use, methods of construction and daily operations of proposed project. If more space is needed, please attach additional pages. Purpose: Replace functionally obsolete bridge. Use: Public Transportation-, Methods: Standard Bridge Replacement methods-, Daily Operations Insress and Egress wi11 be maintained during construction Form DCM-MP-1 4. LAND AND WATER CHARACTERISTICS a. Size of entire tract N/A b. Size of individual lot(s) N/A c. Approximate elevation of tract above MHW or NWL +/- 3 ft (US- GS Quads d. Soil type(s) and texture(s) of tract Dredge Spoil or Madeland; Sandy Texture e. Vegetation on tract mixed herbaceous, including Juncus sp., PhraQmites: also Yucca aloifolia f. Man-made features now on tract soil road and existing timber bridge g. What' is the CAMA Land Use Plan land classification of the site? (Consult the local land use plan) Y Conservation Transitional Developed Community Rural Other h. How is the tract zoned by local government? N/A i. Is the proposed project consistent with the applicable zoning? Yes No N/A (Attach zoning compliance certificate, if applicable) Has a professional archaeological assessment been done for the tract? Yes X No If yes, by whom? k. Is the project located in a National Registered Historic District or does it involve a National Register listed or eligible property? Yes X No 1. Are there wetlands on the site? _ Yes X No Coastal (marsh) Other If yes, has a delineation been conducted? (Attach documentation, if available) m. Describe existing wastewater treatment facilities. n. Describe location and type of discharges to waters of the state. (For example, surface runoff, sanitary wastewater, industrial/commercial effluent, "wash down" and residential discharges.) Surface runoff from bridge and roadwav into canal o. Describe existing drinking water supply source. N/A 5. ADDITIONAL INFORMATION In addition to the completed application form, the following items must be submitted: • A copy of the deed (with state application only) or other instrument under which the applicant claims title to the affected properties. If the applicant is not claiming to be the owner of said property, then forward a copy of the deed or other instrument under which the owner claims title, plus written permission from the owner to carry out the project. • An accurate, dated work plat (including plan view and cross -sectional drawings) drawn to scale in black ink on an 8 1 /2" by 11 " white paper. (Refer to Coastal Resources Commission Rule 710203 for a detailed description.) Please note that original drawings are preferred and only high quality copies will be accepted. Blue -line prints or other larger plats are acceptable only if an adequate number of quality copies are provided by applicant. (Contact the U.S. Army Corps of Engineers regarding that agency's use of larger drawings.) A site or location map is a part of plat requirements and it must be sufficiently detailed to guide agency personnel unfamiliar with the area to Form DCM-MP-1 the site. Include highway or secondary road (SR) numbers, landmarks, and the like. SA Stormwater Certification, if one is necessary. •A list of the names and complete addresses of the adjacent waterfront (riparian) landowners and signed return receipts as proof that such owners have received a copy of the application and plats by certified mail. Such landowners must be. advised that they have 30 days in which to submit comments on the proposed project to the Division of Coastal Management. Upon signing this form, the applicant further certifies that such notice has been provided. Name Ronald LM Adams Address P.O. Box 423 Beford, Va 24523 Name Charles Francolini Address 4 Farmin on Heights Charlottesville, Va 22901 Name _John Maeiejczyk Address 244 Plymouth Road Wilmington, Del 19803 Name Dr. Charles Worth Address 2935 West Libbv Phoenix, Az 85023 0 A list of previous state or federal permits issued for work on the project tract. Include permit numbers. permittee, and issuing dates. 0 A check for $250 made payable to the Department of Environment, Health, and Natural Resources (DEHNR) to cover the costs of processing the application. 19 A signed AEC hazard notice for projects in oceanfront and inlet areas. A statement of compliance with the N.C. Environmental Policy Act (-N.C.G.S. 113A - 1 to 10) If the project involves the expenditure of public funds or use of public lands, attach a statement documenting compliance with the North Carolina Environmental Policy Act. 6. CERTIFICATION AND PERMISSION TO ENTER ON LAND I understand that any permit issued in response to this application will allow only the development described in the application. The project will be subject to conditions and restrictions contained in the permit. I certify that to the best of my knowledge, the proposed activity complies with the State of North Carolina's approved Coastal Management Program and will be conducted in a manner consistent with such program. I certify that I am authorized to grant, and do in fact, grant permission to representatives of state and federal review agencies to enter on the aforementioned lands in connection «7th evaluating information related to this permit application and follow-up monitoring of the project. I further certify that the information provided in this application is truthful to the best of my knowledge. This is the 24 day of June , 1996 Print Name M. Randall Turner. NCDOT Signature GJ���/ (4�z� Landowner orAuthoried Agent Please indicate attachments pertaining to your proposed project. DCM MP-2 Excavation and Fill Information 4 DCM MP-3 Upland Development DCM MP-4 Structures Information Y DCM MP-5 Bridges and Culverts DCM MP-6 Marina Development NOTE: Please sign and date each attachment in the space provided at the bottom of each form. Form DCM-MP-5 BRIDGES AND CULVERTS Attach this form to Joint Application for CAMA Major Permit, Form DCM-MP-1. Be sure to complete all other sections of the Joint Application that relate to this proposed project. 1. BRIDGES a. Public X Private b. Type of bridge (construction material) Timber c. Water body to be crossed by bridge Tributary (canal) Oyster Creek d. Water depth at the proposed crossing at MLW or NWL +/- 2.7 ft e. Will proposed bridge replace an existing bridge? X Yes No If yes, (1) Length of existing bridge 54 ft (2) Width of existing bridge 10 ft (3) Navigation clearance underneath existing bridge +/- 5.3 ft vertical: +/- 20 ft horiz (4) Will all, or a part of, the existing bridge be removed? (Explain) Existing bridge to be removed except bulkheads to be removed to normal ground elevation f. Will proposed bridge replace an existing culvert(s)? Yes X No If yes, (1) Length of existing culvert (2) Width of existing culvert (3) Height of the top of the existing culvert above the MHW or NWL (4) Will all, or a part of, the existing culvert be removed? (Explain) g. Length of proposed bridge 57 ft h. Width of proposed bridge 24 ft clear roadway i. Height of proposed bridge above wetlands N/A Will the proposed bridge affect existing water flow? Yes X No If yes, explain k. Navigation clearance underneath proposed bridge +/- 6.1 ft vertical: +/_ 19 ft horizontal Will the proposed bridge affect navigation by reducing or increasing the existing navigable opening? X Yes No If yes, explain Vertical clearance will be improved horizontal clearance is improved since suDDorts will be located to either side of mid -channel (ex bridge has support in mid -channel m. Will the proposed bridge cross wetlands containing no navigable waters? Yes X No If yes, explain n. Have you contacted the U.S. Coast Guard concerning their approval? Yes X No If yes, please provide record of their action. Form DCM-MP-5 2. CULVERTS N/A a. Water body in which culvert is to be placed b. Number of culverts proposed c. Type of culvert (construction material, style) d. Will proposed culvert replace an existing bridge? Yes No If yes, (1) (2) (3) Length of existing bridge Width of existing bridge Navigation clearance underneath existing bridge Will all, or a part of, removed? (Explain) _ the existing bridge be e. Will proposed culvert replace an existing culvert? Yes _ No If yes, (1) Length of existing culvert (2) Width of existing culvert (3) Height of the top of the existing culvert above the MHW or NWL, (4) Will all, or a part of, the existing culvert be removed? (Explain) f. Length of proposed culvert g. Width of proposed culvert h. Height of the top of the proposed culvert above the NT 4HW or NWL Will the proposed culvert affect existing water flow? Yes No If yes, explain Will the proposed culvert affect existing navigation potential? Yes No If yes, explain 3. EXCAVATION AND FILL a. Will the placement of the proposed bridge or culvert require any excavation below the MHW or NWL? Yes -.-W No s pt, c/zrcusssa„ If yes, (1) Length of area to be excavated f 5Z (2) Width of area to be excavated 3o ' (3) Depth of area to be excavated = 37 fir/ (4) Amount of material to be excavated in cubic yards —r 3 0 l: b. Will the placement of the proposed bridge or culvert require any excavation within: NIA Coastal Wetlands _ SAVs _ Other Wetlands If yes, (1) Length of area to be excavated (2) Width of area to be excavated (3) Amount of material to be excavated in cubic yards c. Will the placement of the proposed bridge or culvert require any highground excavation? X Yes No If yes, (1) Length of area to be excavated +/- 24 ft (2) Width of area to be excavated +; - loft (3) Amount of material to be excavated in cubic yards +/- 22 cubic yards d. If the placement of the bridge or culvert involves any excavation, please complete the following: (1) Location of the spoil disposal area See e. and g. below (2) Dimensions of spoil disposal area See e. and a. below (3) Do you claim title to the disposal area? X Yes No If no, attach a letter granting permission from the owner. Form DCM-IVLP-5 (4) Will the disposal area be available for future maintenance? Yes No N/A (5) Does the disposal area include any coastal wetlands (marsh), SAVs, or other wetlands? Yes X No If yes, give dimensions if different from (2) above. (6) Does the disposal area include any area below the MHW or NWL? X Yes No If yes, give dimension if different from No. 2 above. See e. below e. Will the placement of the proposed bridge or culvert result in any fill (other than excavated material described in Item d. above) to be placed below MHW or NWL? X Yes No If yes, (1) Length of area to be filled 2 ft (2) Width of area to be filled 5 ft (3) Purpose of fill backfill of bulkhead in NW quadrant f. Will the placement of the proposed bridge or culvert result in any fill (other than excavated material described in Item d. above) to be placed within: NO — Coastal Wetlands _ SAVs _ Other Wetlands If yes, (1) Length of area to be filled (2) Width of area to be filled (3) Purpose of fill g. Will the placement of the proposed bridge or culvert result in any fill (other than excavated material described in Item d. above) to be placed on highground? X Yes No If ves, (1) Length of area to be filled +!- 195 ft (2) Width of area to be filled +/- 35 ft (3) Purpose of fill raise approach grades and to widen side slopes 4. GENERAL a. Will the proposed project involve any mitigation? Yes X No If yes, explain in detail b. Will the proposed project require the relocation of any existing utility lines? X Yes No If yes, explain in detail Cable TV to be attached to bridge c. Will the proposed project require the construction of any temporary detour structures? X Yes No If yes, explain in detail 30 inch wide walkway to allow pedestrian access to adjacent homes d. Will the proposed project require any wort: channels? Yes X No If ves, complete Form DCM-MP-2 e. How will excavated or fill material be kept on site and erosion controlled? Standard NCDOT Erosion and Sedimentation methods and BMP's f. What type of construction equipment will be used (for example, dragline, backhoe or hydraulic dredge)? Crane, Pile Driver. Backhoe Dumptrucks rucks and other standard bridge construction equipment g. Will wetlands be crossed in transporting equipment to project site? Yes X No If yes, explain steps that will be taken to lessen environmental impacts. h. Will the placement of the proposed bridge or culvert require any shoreline stabilization? X Yes No If yes, explain in detail Bulkhead and wing walls ,will be used to stabilize fills at stream maraIns M. Randall Turner., NCDOT Ap llcant Project Fume oe Signature June 24, 1996 Date \Kilkenny 04 ` s`t N ols slo94 ///Sfl�\�\ S 2f� y1Y \i t yrs New HWUnO �Swrr Quartet Gull /w nJ� / L \ I K A \ / C O Sine of Kllosrattrs _ M S / o' citil CAPE MATTEAAS NAT1pNAl O 3 S L A N D- I� I OCRACOKE S RECREATE MRF.f_ E SCALE SCALE 0 I AVIE fE M N.C.D.O.T. DIVISION OF HIGHWAYS HYDE COUNTY NON -SYSTEM BRIDGE OVER TRIBUTARY TO OYSTER CREEK APRIL, 1996 SHEET / OF 5 REVrSEA—ic..,�J�� 9Co H Gap C Q Point Northern. Mary Ann .� on3j� - -- ` - / NAT SiiASIIORIs L ,ir:� •�~ :d r\' •�'.� I�o-seper�;::• 1 C /•_.•-pTanksl�.:`;_Polo\•�-ti_��f ,3 Coast Guard St 5 1 ��,• •l•1 • \� , � \ '. o'c •S Lt WindatiA I �:'':•��: ` cracoke,<- •�; �, .1 jE%�. Point I Silver �';" � : • ' ��• Lake y • j>i°,Y�� "`����� -""` • ter' '-_ � I Ocracoke t,k joe_ a ; •...,• /•. Z. Boiler •.: ���i.'• ,'•. /�,� - Piles. 0 6tJl . �M 2 / 4` • •. • • f:,•• Cockle Shoal Lt Q jx :. ;•'.• _ •� / I Pile° LS; f'. A- �% •��=wer rN. Springers : Alt== __ / / -'tie !Point l -- y I Tenl� - +/ I� //- '� 4' C F' Ocracoke i ��•" / _ - ;, �' O Airport; / G O / 4� , Teaches Hoiq, / First Grass Channel Ltio / iix v P SCALE 1:24 000 /::• I 2 p 1 MILE I Secom 7000 0 1000 2000 3000 4000 5000 6000 7000 FEET ll ] 5 0 I KILOMETER 4ti1. , J Coke (C) N.C.D.O.T. DIVISION OF HIGHWAYS HYDE COUNTY NON —SYSTEM BRIDGE OVER TRIBUTARY TO OYSTER CREEK jj APRIL, 1996 .. .. no ,rr•r �] f o -r 91- On v /� �oNAt D' L�/Nu %4DAr„S ` O 41-3 l ° a�Feao, VA. 1 1 z4sL3 d FL I_ rAd { I • .. � �1 arse-s C.Z L' — r i3 ° 0 a.o.B. FEZ. 47-A ! CrMQ1-ES �RA•1teL�u1 { G Z q �aeMrvcTe� f16isMrs ,,,��_ I n H n \ C�/Ak�e7rEtvr«c� VA. Gy.D•� `EX. Bu ��LN EAJ Eo 1 i �•jNTI �Iw µ �1�1L IJ�►rL� JOr+�1 MAEI8,7'-zY 4 PL--1M 1114 RD. I,U,un,�c �e,�.►, i�E f���� E IAp-� -> ae EXc,AvA-r--D • So 2S o so /"-Soy 9 J oo /ofoo/r-oo -STA la +Z-' -7 3 19 �--r'M �Q1DGE B 21 DG C S C">i-T E,L . -a f��aPoSsD � Cj•Q1+oe EX�StiN� ¢ 1`I GZ-.r I �b ELEV. =S9•S---) Ey�•s-n,�� �osrs �-W5 l EL. = 94 •`7 417-/ 9C. 11.11 Am Imo- QoPoSe� ��t�'S PaSED � G,2nnE LT • i� A p_E A --I,, 'Sc- M 14 L.-) 4366 -,?�cu.yDS. EL�V4Tio>\15 P-- Assu r-, EO //o /,0 0 5p LT � SD I �f Rl3�E /0314 /66 SrP, 9 +75 So L-7- 5o et I 'P(Z0 p oS E.7 Ce . 6 (LADE EC.=A3.o N STA /0 +_7 8 !�-CEVArio 15 APLE A5Surlc0 1�l�-r'u M N.C.D.O.T. DIVISION OF HIGHWAYS HYDE COUNTY NON -SYSTEM BRIDGE OVER TRIBUTARY TO OYSTER CREEK APRIL, 1996 SHEET'5 OF 'S 'REVI.e'cb Su�lEI 9% STATE OF NORTH CAROLINA DEPARTMENT OF RANSPORTATION JAmEs B. HUNT JP_ GOVERNOR Mr. John Maeiejzyk 244 Plymouth Road Wilmington, Del. 19803 Dear Landowner: DIVISION OF HIGHWAYS P.O. Box 1405 Elizabeth City, N.C. 27906-1405 Phone: (919) 331-4737 Fax: (919) 331-4739 June 24, 1996 'Sa4l ��,t a t. C%� ckX,., bC GARLAND B. GARRETT JP_ SECRETARY The North Carolina Department of Transportation (NCDOT) is proposing to replace the third bridge over a tributary canal to Oyster Creek at Ocracoke, North Carolina. The old bridge is functionally obsolete. The work proposed will result in incidental impacts to one or more designated Areas of Environmental Concern (AEC's), and therefore will require authorization from the Division of Coastal Management in accordance with the Coastal Area Management Act (CAMA). The attached form is submitted to insure that adjacent; riparian landowners have an Opportunity to review and comment on the proposal. Please review the attached material at your convenience and, if you have no objections to the project, please return the form with your response within 10 days to this office. No response from you within 10 days following receipt of this communication will be construed to mean you have no objections. If you do have objections to the project, please forward your comments to: Mr. Terry Moore, District Manager Division of Coastal Management N.C. Department of Environment; Health and Natural Resources 1424 Carolina Avenue Washington, N.C. 27889-2188 Thank you for your cooperation. Sincerely, M. Randall Turner, Division Environmental Officer Planning & Environmental Branch -Division 1 Attachments cc: Mr. Terry Moore, Division of Coastal Management RE ADJACENT RIPARIAN LANDOWNER STATEMENT (Hyde County: Oyster Creek Bridge Replacement) General Statute 113-229 requires that riparian landowners with property adjoining a proposed development in an Area of Environmental Concern be given ten (10) days in which to comment on the proposed development. This form allows the adjacent riparian landowner to express either: (1) that he objects to the project; or; (2) that he does not object and desires to waive his/her right to the 10-day period so that the processing of the application can progress more rapidly. Of course, the adjacent riparian landowner need not sign this form at all if he/she so chooses. No response within 10 days following receipt of this letter and form will be construed to mean the adjacent riparian landowner has no objections. i; am an adjacent riparian property owner and am aware of the North Carolina Department of Transportation's plans for replacing the third Oyster Creek Bridge on Ocracoke in Hyde County. I am further aware that this work will occur in one or more AEC's and therefore will require authorization from the Division of Coastal Management in accordance with CAMA. 1 have no objection to the project as presently proposed and hereby waive that right of objection as provided in General Statute 113-229 I have objections to the project as presently proposed and my comments are attached Signature of Adjacent Riparian Landowner Date: SENDER: o ■Complete hems 1 and/or 2 for additional services. I also wish to receive the n ■Complete hems 3, 4a, and 4b. following services (for an °n ■ Prim m your name and address on the reverse of this form so that we can return thus extra fee): s card to you. ■Attach this forth to the front of the mailpiece, or on the back if space does not 1. ❑ Addressee's Address V p permit. ■Write'Retum Receipt R p equested' on the mailpiece below the article number. 2. ❑ Restricted Delivery W ■ The Return Receipt will show to whom the article was delivered and the date e delivered. Consult postmaster for fee. a 3. Article Addressed to: 4a. A Number d I FL /sir ..io h N /Yb eie t zc� fs ��`� / �� A7/ L � E o M ��� t'ly��a 4b. Service Type - d o G� Registered ' Certified ❑IM a:(�r �/�7//iY�( '� /p 9803 ❑ ❑cm Express Mail Insured E u g 'Retum Receipt for Merchandise ❑ COD in _ 7. Date of Delivery G� < o 5. �eceived By: (Print Name) 8. Addressee's Address (Only if requested u c D r A PS Fort 00 r 1, vecrornuer 1Z1y4 ...,,,,..,,., ..-.-,n Receipt I SENDER: ;o ■ Complete items 1 and/or 2 for additional services. I also wish to receive the ■Complete items 3, 4a, and 41b. ■ Print your name and address on the reverse of this form so that we can return this following services (for an extra fee): j card to you. ■Attach this form to the front of the mailpiece, or on the back it space does not 1. ❑ Addressee's Address d c, permit. ■Wnte'Retum Receipt Aequested'on the mailpiece below the article number. 2, ❑ Restricted Delivery ■The Return Receipt will show to whom the article was delivered and the date o delivered. Consult postmaster for fee. 3. Article Addressed to: 4a. le Numb a Mr. CJAr,�s FrR.►z o/,v�' S/ %� C' / & 0 4/ �Ar/%��/(�fA.C� �7t �L',l� 7 4b. Service Type ❑Registered to ��/l�� ertified ❑ Express Mail w �$ f vC!� oZc�9d / El Insured nw,/ Return o [3Receipt for Merchandise COD a 7. Date of Delivery � � -?- 07 5. Received By: (Print Name) 8. Addressee's Address (Only if requested and fee is paid) 6. Signatur d r Lssee or Agent I• i. l A-11 PS Ftam December 1994 Domestic Return Receipt �ItNUtti: ■Complete items 1 and/or 2 for additional services. I also wish to receive the v SENDER: ■ Complete items 3, 4a, and 4b. following services (for an v ■ Complete items 1 and/or 2 for additional services. I also wish to receive the ■ Print your name and address on the reverse of this form so that we can return this extra fee): ■Complete items 3, 4a, and 4b. following services (for an card to you. d ■ Print your name and address on the reverse of this form so that we can return this extra fee): this form to the front of the mailpiece, or on the bac if space does not 1. ❑Addressee's Addr@SS card to you. it permit > ■ Attach this form to the front of the mailpece, or on the back if space does not 1. El Addressee's Address Wdte'Retum Receipt Requested' on the mailpiece below the article number. 2. El Restricted Delivery E, ppermit.■ ■The Return Receipt will show to whom the article was delivered and the date a a, ■ Write'Retum Receipt Requested'on the mailpiece below the article number, 2• ❑ Restricted Delivery delivered. Consult postmaster for fee. ■The Return Receipt will show to whom the article was delivered and the date 3. Article Addressed to: RaNiliZnl 4N,U &411; '57 P• o . fox �a-3 Received By: (Print Name) 6. Signatu : (Addressee or Agent) n , PS Form 3811, December 1994 _N v C delivered. Consult postmaster for fee. 4a. Article Number a)o p a: o 3. Article Addressed to: 4 cle Number Q 72 50! /�� 4b Service Type • ❑ Registered Certified ¢ a o n '��� f/ 21-sc J ❑ Express Mail ❑ Insured S Cn f �1F�c��X �1F� El Return Receipt for Merchandise El COD :3W 7. Date of Delivery Q 8. Addressee's Address (Only if requested and fee is paid) t ir 5 R ed By: Print Name) 3 6. gignaAddressee or Agent) i. X Domestic Return Receipt T PS Form 3811, December 1994 4b.Gervice Type 440- �� - 'F g Istered I/ -6 rtified 4 `r Ex »ass Mail ❑ Insured �tUrn Receipt for Merchandise ❑ COD 1, Date of Deliv 8. Addressee's Address and fee is paid) if requested c Return Receipt