HomeMy WebLinkAbout75555A_Perry, Jr., George_20200515
N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date -I J � L —'
Name of Property Owner Applying for Permit:
13YC Y E LA�0 d Y-nY►
Mailing Address:
f'incs V=-%e_1 "C. Vl CA k 0
I certify that I have authorized (agent) LCA Y1 P(IfY -e-- to act on my behalf, for
the purpose of applying for and obtaining all CAMA Permits necessary to install or construct (activity)
V � C-Y isY) YJU 1 V )Pail at (my property located at)
135
C'Y-A � V-1
This certification is valid thru (date)
Property Owner Signature v \ \ Date
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent toV)yn* (gym �} p1�YCG's
I 22 C (Name of. Property Applicant)
property located at �7=) ? �o� r .01 e r2n \ Vl U
on
nt Waterbody)
,ess, Lot Block, Road, etc.)
Y-'-'A i V)
(City/Town and/or County)
The ap licant has described to me, as shown below, the development proposed at the above
oca � n.
����� I have no objection to this proposal.
I have objections to this proposal.
You can mail any objections to 401 S. Griffin St., Suite 300 Elizabeth City, NC 27909
If you have any questions you can call: 252-264-3901
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
60'k Gk�t
( roperty Owner Information) (Adjacent Property Owner Information)
LAAL El��Al'l
Si ture `' Signature*
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Print or Type Name Print or Type Name
2-'1 M�oad ILIA L.1FVo,J
Mailing Address Mailing Address
21 el I o & 1g: �0 N .(- 12cOL)
Cit /State/Zip City/State/Zip
�L� 2. ZI'l . o►� ��Y�doc�ry a5i= aoci yS 7N
Telephone Number/email address q�UNk UrATelephone Number/email address
,Jl
Date Date
(Revised Feb 2017) *Form is valid for one calendar year after signature*
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ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to 1-NnA Nel() i" ( PY(-O 's
ii {{ ame of Pro e[��ty Applicant)
property located at 1 t�n IMP lr:l 1 Yl ►J 1. Z�G( 2—q
(Applicant's Address, Lot, Block, Road, etc.)
on C��,�iCij,�JAI ?='� in N.C.
(Adjacent Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location
10
I have no objection to this proposal.
have objections to this proposal.
You can mail any objections to 401 S. Griffin St., Suite 300 Elizabeth City, NC 27909
If you have any questions you can call: 252-264-3901
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
(Property Own r Information) (A jacent Property er Information)
I
i ture n re n
Print or Type Name Print or Yee Name
Mgilin^g Ad ress /J� /� Mailing Address
!'� V L :s 1Q � N C, 21 " V Co I e r-e , ,mot Jll` E- -2? cl 2I'
City/State2ip ity/State2ip
1 i I2!S2�2�?-Sso 6- fry ,i•cor,
Telephone Number/email address G1i C�I'►"Telephone Number/email address
i-(5--1q 7-\5--19
Date Date*
(Revised Feb 2017) "Form is valid for one calendar year after signature*
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Kathy Pierce
S. Perry's Beach
Clorain
Bertie County
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