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HomeMy WebLinkAboutHarborside Club @ 70 West. , I . _ .. - .. : . " ......, '- �' _ . . . I ,I �.. . . I I . I . ,.,. - ' I . 1 � € i.-:. i. . 4I , !- . - C CAMA DREDGE & FILL - �.'.. ,--" ., -.,., ,­�` .'- I� .. �I. .,. I' .,.�.- .:. .. .II, -I.._1 ..�t...o .. ..I.. I.._ II..I I I . I -. I � -1 I . : � , I . I.III . ..4 .' - I . a - .I .-. ..I. �. N, ��.I .,, .- .., .: �..I­� ..II. :t;. .' 1i.�i,.1I',;1..,.,1IIIjIi;,,i!�1:I,.- I.k. I... I, t . z t , GENERAL Pg R M I T q B' C D : u - 1,a1 t ' > r �....,x _ , Previous ermit # 1...- - . .,F I . I I - ;t' : '.... tl:' . E". ❑ ❑ . ❑ ❑ Date revious ermit issued r ,. , r¢.� ` New Modification , Complete Reissue Partial Reissue p p N -. �' ` �- .. ',,, .-I ..1I �... ..­ ,,.�­, .II ,-,1i ,-,I ,��.I. 1Irl. ._. I--.4-. . ._ r . -.., . .,., . I LI t .,. �: :. -. , , ; , ,,;w 1" • 7A 'Authorized' - the, State of North Carolina, De artment of Environmental Quali . " :, Y . P tY I . 1"1 I,II �. ;" I1_ .: 11; ._, �- -. .. .,I 1]. ,.k' ": „' .. J , E >.. and the. Coastal ,Resources Commission in an area of environmental concernpursuant to.15A NCAC- , � - ,., f, .. P 1. .Y, III ., ,I, FT I.I�. .J...� , . ,'. s . Y t > - 3 : . Y . 1. *-, _.I,..". ul . Res attached. ' , � ,. , _*. 1,w. I ­ ,' - ' ` licant Name ,' { 3 PP .. ��. .. :, 1�,�. :� .1 I1..;: -. .II � . - IIk. Pro'ect Locatio n CO un '. . 1 tY . ,_,, ., _ "-' _. .I 1_ ­, -I ,I.� .,.. ._.I ,1 ���. _iI G�1 "I.I. t , � ti �' 1 , - 'ai Y., r.' >'..• 1. . - ,t Address T) r, .. .I ,�- I_ .11 . . 1 ,€ tate Road Lot # s Street Address/ S / x� j A a �� tl' �. � } 1 .:. I �-. ,:4, i ., .I .+ �' I :I. ..t S 1 - _ ­ 4 e f i:' - i , : V Y .' - Y . f.i. '" ' t, :J 1''!.. :L .�-� l +cif C. h. i ,� p, - _., 1 t' qQ ¢ :` ,e.. F .C� 4 t Y .. . ll a a',..1. . .� • , y. ' 'Z t• A' ' is .. " 1 1 .. s C 1: -- '{ t ZI P CI �� 9= Sate ,. , I '� I _ . j - ,..1. -. ,: ­; .-,: ...: "�1.I- ,--,: I.I ." i_ �t .� ��. -��' �II.._II -..' � ! . ' it �,,u(4..._ C. �i. .. i / .. h4KIVY,.'.r:••�yl;Y'.i'f!'1!?'h'^'n� - _ C ", � . I l 4 '�?.N- 'Yt,. S .Y 'b.-::.,rY}.,j .fs .iNY`,.., A j f 1 .1. 7� � i, i .. ' - , 1.� Yy L ­ Phone ' r U . - II „ „ E a I. .1I1.�..I �.I- ._1',.". #.. .­, `- I.,. ­I..:...-1. -.,6;.,. I...I ..I*. ._: .!� � w-_ _ _ - ::.1 ... . ..1 I1 _ '.l •1_ t. -I�_ . SUbdIVISIOn �I .�11 ` I� �IIi�, .I .. I. -.I..f,....I-, 1. I-. .'."'; If I. ..f I�... .,. ... -.. I ;' .., . '... r • . "',, .� 1, `!K•Yl4M1:'I.=l ab , t'`-' Y{ .. .' , -'% - .A. T r,:':: ...M�.�:j, _ h; � 'g Y' {: . a L . . :i a f y . E:' t 4 A hOr'zed A ent M1 '.I- I- ., .I .I..I :".��;,1..:. I.­�-,.�- 1 ; . , . I . . f ,h 1 n. .. ♦{ .( 1. :.. . -II,. . 7 v 1 t �� a:2 : .'- `t s S t 4 -�r ,, . I i y. ZIP c'. C tY :V. : I-. 5 I '., .I1 �� 1I I� 1,­..,. .. :AI-I-.,. ,, ..­�S�, ,.. .,. .".I I.,II_.. ;.-- .1-I1 ,1,� I. . - ;.. .�. ­ . N::� .. .. h a,, * Zi. �� .. TA E PT D CW Q'EW P S � s i. i1Z�1,' �,ri.% ,I 1I I I.­�. .­-� . I I .. .,-I I , . L i. f ,E.. `,2 :'J " ­to ai�i .�... •I. re Ora . 1 7 .e :3 tt - ', 7 t: Y r B in Rive as Phone # ��. �� :�. , (' I .I.r 1_ I.. I. ::-.:..1 ,..? .._I ."4,, .'...4 .;. -* I... z7'". I� ,�.. it C:' �. a;.y4 ,� D .; Affected ' / ':I _ ;, .��1 .' ,. -- ,1,.: .'.... ,!..I�1.�,,% ❑ OEA ❑.•HHF ❑ IH ❑ UBA ❑ N%A. !14 AE.0 :s : .I I- _: . Ad'.' Wtr. Bod .i,.. A. f' -1 . r(nat: /.man /unkn) ,., . � �I ,.p 1S ❑ PWS: . �I,0 r ; . ; : . ,. .,,-" ,I ., .I ..' I t rs ORW:` yes /. no PNA yes `/ fno . 14 _ _, :� .-i. .. . ClosestMaj. Wtr:� Body - ,.. _ . 1-, f k :i f :i, , A .I I�I �- �.z�,. 'I,J taka ,. b.. S 1. �."_ .1. "." .''I .. - ` .t' t 1, _, * 1 :' :. �1 .. .,e, 't E -., t- - ,s . F r !, .tY tr ,. i A A i ,. L- J .. .i. r. e , - r'' �'r ,v ,, a r T f Pr c Actwi v '�•t d e :o o e t ��� , I - . .�- .II ­'L ,- 11 .��- ,.I ��.-q .­. ',I%_..I.1.-. ;­,1I 1,X .I..- 1.-,.. 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Float'in Platform s ( $ \) € " :' a E i .tin € ..._4..._......:_�.... .....b... ....._. .... ....... ........ ....... ... _ ...... ....... ...._.. .. ........ ....... ._.._ ... ............... .... .... ._ _.......... . i s _..... 1�, y � .I ..�. .I. ,�-4 .. ....-- .,.' t.a ..7 .._,, k "_ - Fa Fin er ier s € [ g P O € € ,II �%, -II.- .'I-"�i1-­ I ' j r a 4 r` j f E{ t ,, A . x' �- ._ -;J y -I��,", . Groin len h .. I IS • --II - -'.I is 1 : .....1. �- > _.' :; _ 9 TII! .�1 z I� . .�, i4 , , r: t4 _ ..m 1I.I .I ;,1- :�;s...I ... . : .� �!..I. '71 L- !-I 1 t �.�0-, � . r . ,' I� �.��.,. : . E.. € t ",I. . !! !' r. t , , ..I� € 2 ` '+ I ,; - 3^ ' i_"0�j,,4­, . number r. _ !,. .. .. �, ram. I :- . i '.1 i I ;.-.� ' �I�. I E ,:` .E...- i f ., .'y.. r- $ � I ..: E[E f ­.. ..., �.-5 �• . -. .. I,�1�� _ 5��j ,I-.. I. .4_F t Yd. tr �, �Q'. .I .II .. , ��-ZI,.. .­ , :Bulkhead/ Ri ra len hW .. P P I.1 - -� __ __ . W .� _I ..I" ... -. 1. ..-I . I. ri?I 1-�,,1 .I� 1.. ,. X. ?i.,:. . .I_. - 14. I..- I..1 .,.�I 1�.:1-. . --i �'� EE{ _I.!,I...".L. ,. .�. :" ".� '.. .I..� -' .� .. -._. N 1 I....._:_ . T r f: ..,;;,.I­. .[.".1i. . . I y - ' av 'distance offshore . c - . g .. - I: I j � .* I. .II,- - iZ -I _ . �I-..�I 3 � .R 7. ;. ..s,� , -. - -; ­ ir' ,..; • E tI .11I..�.-( ,.4 .1..... III� I.. II . ' �1 -- _ _ •� . r i 1.:;.. ,. E i w�_ .,.... I,,p..�-�..I E• ? i 1: i# , - I , . max distance offshore' _:° '•..� �k 7 Basin, channel tr I.II:. , I1 II: -.I".;� �._. 1- _I - z­ !., � .'.- ,.,. ,I �.. ,I. r. .., E t V i� - ..� *. �_. I .. 1.. .I...' r .I jl I ,� i i I.I , - -- -I-a _ ( -I 1�� �-, r 4 iE 4 'ZJ a _.I� - . I ,�... I.,. ,.1 _ , } a . y (([ I ' .I. •. .- ..�, I�.-, "? -,-.I I , .' ` ,7;It.. ' ItC C.. i -.,1:-� .-�--I: ..!.- .....f.._........-.e cubic yards t_ It .. .:­.., ...............:.........___ 1 1. ..:......... ........... I,�. ....E r E . �...m�.... _. ..*I- ­� �. .. ^ `N I� �-.I . [ � if F a ..aII.!I. _-_ I _. I. ; a r1 r ; z i ' i 1 1. ..` .. _..i1 .1 E �. �..., t f Y ` ': ..-I ,1 'i d I t -.I :I� - '. ., 9 - Tr.i - i R�" - Boat ram , I..-. . I :, , ,� ., .- ,�.:n. I 1 -­. . Boathous%'Boatlift t-..:= , ,. .. I. I�f, 1. ... ff .,.-' . .�. � "a .. .I . " .r 1 ....1- ...,1 , -... . I.t II. - E E _1,.:.,. 1,�. 1, IIiII_"".1.1 % ,.--..I ., .. :: s . ., �! I ._ I] I� 4 t ,-,1. . I -. I,L, .-.,r•,I ` by Q ,,%` -% �. ) J �.�.I .'­.I. I. , , _ -. . '- I. .YI1,4..�I .. 'I�­..�I'.III. , I -, . ,, ..,e : - ,. ,.. :1,1 :., - ..,......... '� ..... .�; .� ..............:............... ............................................:.............:.............................. E o E E ,..,-..,1�- _............. ,.................I...:,.... q� E ...............o......................_...,:............._ , Ir.. ......._...,.................o...............:..,....................._................... . I.e € ,I .. .... I II ........ ........ ....... . .� I_- ........ .. ......., ... ..._. 1 .._.... .. ._.... ... ........ ....... ... I . k?` t �, Beach Bulldozin . : I I EEE[ ;. , . 1.. ..- ; -. I. ..I � W . I. II.. I1 I .. i r [ € d,_-.,,-,_ •„-,-,- . : _:..... - _,:,-_ ..-......._ : : E i __,,._._?_ ai ., m. .._ I�.. .I. ..* .. . .I � ­. 1.._ _,. ._I, , , I € _ gym€ �.. II �� e.I. . _ I I.', II- - _ .. __ I. _ ,. , ? ,,; . lar "`,,. y ., J ;: 4 T .Other ," �, � _ � r , , [ -- . _-_.__ .*II II. i; �I� I j �a . .:,. I .k : , I -. j 6 , �' 5 . ' , .. ...�I - ' .. .. ..,. i .1..%,I. € I .l.�., . . .. .. .1 .* .... .3.­ .:-.. 3 E € € .... .. .1 .�.I .. .7'," ..t.!.. .. .-� ..1-,,.IO ."..,.,­I- . .�...1 .I .� .­I_.,I [€ . .i .. . .-. .. ..I- .... . -I. -1. . �. -.I . . .. -'II .�-p. E i €'€ ..'... -� .x., .� .. . ....' .'1 ..) .I ., .11.-� .s,..;. ...; .I1.. .... .. .,.. ....� ..�..,,..-.., ... ., .:.I.-q ..,fI -........._...._.._ LII ... ............_......... ....... ....... .... _. ..: ........ ,.,. _. ........ ,. .....:... .. . ........ ., _ . ✓ t1 ..,. S4 � z ..I . t r.c;S Shoreline Length -. ,._-� I -, - -. . ' I i. . .:1 .I. I I I I € _i ? � E I 3 - -.I . - _ - ; , 1 • w . t ti . ,. , . not sure es no_.............I...............................I.........................._................................e...............,..........................:...................:.............e...............:.........,...:.............................................................,..............,..........,.,...:.............................. SAV. Y .I.' 1,, € . € I E I € I E .,�, .II1. .,!._ { .. ,....I........ . E ......I .... ................... -.... ... ....... ........... - _....................,... ... ... 'i , t ,, ,. ... .. . . - 1. I I i € € ..,I-.- �. E i . E - E I1,.' A..JJ- .. . Moratorium: n/a yes no , 1.-� • .; I.,r-,'. ,I.�.I II,:�.�. . ,, -, Photos: es "no Y ., .,)�.- "1­ .II. II .. I E __....... t ,.7.. I Ii ^ {. mm .. ­ I€ E . E _......... E.__ f;;.1:!!::..:,;1.i!:::::.:::::::::::.:!:i.:;::1i::;::!!:::t:;I::;I;:.:.:::::;::.::!.:.::::.i.!::I:::::::::::::::::... .I __ - -�, .,�..-,I. .�,.1..� --. € _1. _ I­ .I _ T i tl t . ,,. i€ Waiver Attached: yes rio 1_.,. .;1V .,.,; { .- --- I .- 1.,- . J� II1J. I� ft1 I,�,.I.-_� . r .-: ,- Ii.,, , .4. I I I A: buildin ermit ma be re wired b g P . Y q Y '� I_ : � 'y' ` �J­1�., .:.. ; .."- - ' . ? ; 7, II ,*.". ., Z. ... i ` ; .I "-. i t ' ' 4 ` , �' � , ,. "..� , . . `' - -a 1�... r r ,i, �' I .'; �. . ,# '. E . See note-on-,backregarding River Basin rules. . ' ,,II .I -77,".. I,-.I, ; "., -,-.. ... .L1 ; I 1. � , ­ .. . �:, ,d iw".-I .... . . !. 1I.� ..- �.. - I >� . I� (Note Local Planning Jurisdiction) �.. .I:. 1. . � . ,rI .� . 1 �,.� "_.I.* Notes S ecial Conditions. L , P .. . F I1- ,II .��.. ; ,. t: - ... 1"v7I..1 I • j � ,: II' .i ; s. _.I9 I ,... _ � � ,I .II ' 1,�. �I.-'.­�-:��� . �' �I . 3 k ty �I: .t eI. I--4 ­ 'l i;�- -,.,II1 ��. ... ; �I �� .-ii.ii.i:::::i:i:i:.;:i;:iI:.i::!:::�I:.:!iiiiiiII - . . .- I-I .".1 . . .- i.. . �.�.. �--:..� �. I �� ' .a. I.. :. .,�,�. "I�.%-.. '!...- P.I�.. _ ✓ 1� , _1�I .1. _, ,-. , . , i�- .. ­ I '. ..-:�­) I . .,* rt 1: -., l�',,1 .1 .'. .l--..'I�� ..;- .. , i . I .� .. ...., -i.. . . ,.. . . .,-: .�I '.!,.' .,-i­!�- I",`--�-_' .: f I { ' - '- tr a • \ S " ..1.,� �1..: -t. .I.. -,..:II -., �I .. �I. ­.��!I �.�. I�,. �;...� �,-,- .,i�w .�..1 ,":.II;1 ��.. :I ;� 1 .. -, ... I .,. ; ! J ' - - . , W, _ I ,_ , , , .� ..,�. ,� ` - , � !. I­-.; ,, a ..-. .*,:. .. ,. I. ,.II� ,.fI.. .t ,� ;. �,.. ,.,'I. ,� :. t. r f' f 1 e I._-.-.d -o., 4 ," !,I ,_ �' .I'1.I: . I -, . ,_,4��­,I6­�: Agent or Applicant Printed Name . ­. .. ,0T111 1-.! �I�.. I � , ,, ­ I Permit Officer's Printed Name` � ram'" .' .I� ;- . .I :--: ..-'�I,.. ._ .-.:.. I.' :.."--,��,;1j*'!.�-; . I I . , .. . t Signature'Please read compliance statement on back of permit ,�� .1I.-.._ :II .1 .. I; _1 r ., X._ . _ . III'- . - "" ! !" . . . "Signature _* I"� � .Ir. ,1*I..I­1 l,,,;-,j,-;_...��*_,--"",�'-,,i,.',.. 1.I �I-., I..-,". I� *- ,.:. I�, z , N _ : � I ,.�t . � I� _- " I,.I ,li :Iq.�. �,. L4'.4 �. ,1 1I 1. ,, r- -, I-.. ,-.I1.f` ,, 1 i, ;,,,-,� ­- - �A S` Z t 9 ,.' 1 ` .n' J - I. .._Iw I. ,* t.r' t i ,. t toe s v. I ,'!­�,�:,;- �-I 1; a: II--.. .,,. ,­,*­.� .,.I. APPlication Fee(s) . • .. . . Check# .. I.1 . . Issuing Date . Expiration Date.. . ee i.✓ ®.GE &. F1 Lis r r r A B C. D <4X Previous permit #�ERMIT ^� ation 0 Complete Reissue 0 Partial Reissue Date previous permit issued r. Environmental Quality of North Carolina, Department of Environ ate CeS Commission it-1 an area. f environmental. concern pursuant to I SA NCAG r ��~ f : r.. F �t. ,4 1 _ .E Rules attached'. L. ��. t; ; � J` { r .,: `' � { 5 e j 3 _ t = ; _ �'� f '; ' 'y PjLocation:County �>J �-- ro1ect . - .wr<=;•a �:.N- j !-..a•.^S�+Q,tsWl+M :3Y � ....;� ^.. 3 -.,<� A � I .sue � . 3..�• ".� J Street Address State Road/ Lot #(s) € v s x ' _ State ,F ZIP z_ E-Mail Subdiv 2# -�, .,. 'f ent. ity •'.n ZIP x�'4-s �e •sf_�s.. - '� - r T ., i '��� •� � �q`�.`�X '� 1=� - a 4 •rp�'� l ES ��'s Phone #4 =t< j g R er Basin g f s f C] oEA 1-1HF El LH" ❑ UBA ❑ N/At F } -,vnc- y..<� f. Adj. Wtr. Body _ £v nat Jman /unkn): c ❑ ■♦ • V . ! ,+•'mot. r Y 4y I !'» jo Closest Maj. Wtr. Body, ., a QRw: yes no PNA yes / njo _ - f• •�� - T � : � ��- •-• � :�' 1 i- I' � ) ! y ! '= 1� .f YPe of Pr joect/ Actays tjxN� ���. a � � .."'.- S .� � 1 �,NF i .i ,S .-.�e!'- t� _ _ • x �:�.:��• �° � (Scale:' - k/ `Pier (dock) length-..:>°� Fixed Platform(s) Floating Platform(s) Finger piers) Groin length--' ----- number Bulkhead/ Riprap length----- avg distance offshore-- -"'-- max distance offshore Basin, channel cubic yards Boat ramp Boathouse-Boatlift Beach Bulldozing Other Shoreline Length SAV: not sure yes.. no Moratorium: n/a yes no Photos: yes no Wnivor Attnrhprl• vAc Znn -�TIT T 1'--_- ' _ i •�� .ax �~ i � r � � (j1 y� f � t.: • �t1 ' � < i _ I t • k c�, .!--�-�n,}�- .o� f �' { 7 .7 ? f i �.�. .1�"rfli..s i t �� � S t� �� J €'� -jam � �, _,,,r_~-..-" i �.,c-.w _ EJ� i ^�--______� ' sc' [ E € s t,.. t i f � I v� � = .ft � 9 II � ,I�•�~r `' - � � - } ' zr '� s ' J€ Q,>'� �K -' I . ? _ ti �.r:{� i r . x _ ij�.��..... -. ,,,mot � - __' i (j_" 4 r{_3• t 7 � rr ` �a�f ,.'{' � i � .� a � i � _, € � € , � _ € 1 � € € .•{�- ":•�: •f'e � € I € �-}}jam• t1`."' ''t ? - rj V •7''' ;r ':,r, +-€ - :� € ° Y?� 1 i : It 5, t i 3 - ,.�.:. €. t € } �€ La'. r` i f •r' i } _ Al � �;,€ .,t. `- 1. t € � - �_ t. t jjt C � .�✓..` wtv?Sl,�:i-ri7ia.' _+n'Y 1 IT �.� t ~ ..s_�%1 f.. �. 3t _ T ; ? j. 0.<�•'sax "' € 3 S � I a ; .R T• � s : � �.; �•�' t I I 21-t itil ��,.(t y � t � � € j il. :i :c' rF AGENT AU RIZATION FOR-CAMA PERMITAPPLICATIGN operty Owner Requesting Permit: de i certify. That f have. authorized . Agent 1 Contractor Jo act on my behalf, for the purpose of: applying for and obtaining all CAMA*perm its _. necessary for the following*.proposed, development: An� Y�v,4� 6 � 4 at my property located at . in (.ih�f�'T County. . i furthermore. certify that. l am authorized- to grant, and do in fact grant `permission to Division of Coastal Mana.goem* ent staff, the Local Permit Officer and. their agents to enter on. the .aforementioned lands in connection with evaluating information related to this permit application. � s Property Owner information: 17 2,0 Signature' j � � 2, 2/ z 3� Z y 2 (ol 2 7/ Z Print or Type Name mom 271' 3 01 311 3 Z- Tine 3 � � .37` 3 9 '1 /` q 2-1 Date RECEIVED This certification is valid through / � ADJACENT RIPARIAN PROPERTY OWNER STATEMENT 49- -761 4AeX7-- s certify that I own property adjacent to V _ = (Name of Property Owner) ��� �/� located at (Address,. Lot, Block, Road,. etc.) artfil Caw , N.C. =� , in (Waterfbody) (City/Tow and%or County) The * applicant has described to me as shown below the development proposed at the above e iocatio I have no -objection to this proposal. _... -----=---- --- -- I h av_e_o b j � c��o n��to_t �t'ts�. p rQp o s_aL___- __._-_-:-.-..-------.------ .___ �._ DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT (individual proposing development must fill in description below or attach a site drawing) l��w--�' �-,�r� s .>v� �c � s�-�� 5 do, c.k S o� �-�o�t5� cLL /u�lNH� �.D�t'Uk PPALA A-0-EN WAIVER SECTION I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be'set 'back a minimum distance of'15'from my area of riparian access unless waived by me. (if you wish to waive the setback, you must initial the appropriate blank below.) l do wish to waive the 15'setback requirement. I do not wish to waive the 15' setback requirement. (Property Owner Information) Print otType Name P.o.i�vx' .3j Z, Mailing Addres =! 40"RaA�� CitylStatelZ-- 1p Telephgnq Number FrOM (Adjacent Property Owner Information) Signature t TVZ Print or Type N17n Y P 0 .r SC/ Mailing Address --- /v,<_ City/state/Zip 7 Telephone Numb r R$:C . D Date (Revised 6/18� � `�j� CTY c7 I ADJACENT RIPARIAN PROPERTY OWNER STATEMENT b 's certify that I own property adjacent tod - (Name of Property owner) rt located aty2�" - _p Y (Address, Lot, Block, Road,: 2ec.) inmo/�MiO�C, N.C. (Waterbo'dy) - (City/Tow and/or County) ff The a licant has described to me, as shown below, the development proposed at the above pp Io.cation rn I have no objection to this proposal. es _. I ha j e cf n_s t_o�th Ls_: pr_o p o aL_^ _. DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT (Individual proposing development must fill in description below or attach a site drawing) ,�in�T�t'T,� wj �if�-✓f �oc,�s 17�g�..b���' Lb le, e_0 - WAIVER SECTION I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set back a minimum distance of 15' from my area of riparian access unless waived by me. (If you wish to waive the setback, you roust initial the appropriate blank below.) I do wish to waive the 15' setback requirement. do not wish to waive -the 15' setback requirement. (Property Owner Information) Si40� A�� ature 409#U:e 4z Z"4_1_,__ Pr►nt or Type Name Po. e� 39 Z Mailing A Tess City/State2ip Telephone Nuliber � zlsr� Date (Adjacent Property Owner Information) I>C JAAV�Vk. 5 Signature Print or Type Name -7 4&kE 6�c �r�g, dress Ci7"y/VG c�dv�� City/Sta%/Zi 25Z—l2G - ?6 S5 Telephonq N tuber Date l a (Revised 611812012) "�-- .: T) `r . a C A ,