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AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT N0. PLAN NO. _ � PARCEL ID: g71Q • "r_7 • nil
STRELr AcoRm: 3D Z W i oo aCy -wf--
STA�1,! C
Please print;
Property Owner: OM r] A
r ..�.7Y/ Al
The Lindersic,rred,, registered ProPertV owners of the above noted property, do hereby authorise
of (A ZCZ
- ` f AQ,wt) (Name -of consulfing fkrm)
to act on my behalf and take at actions necessary for the processing, issuance and acceptance of
this permit or cettificaWn and any and all standard and special conditions attached.
Property aw les Address (If diffemwt than property above);
Teiephon,
*T
WC hereby ceriiify dw above information submitted in this application is true and accurate to the
best of our knoy4edge.
`off Authorized 5k)naature
Date: — —

�A iAWSA RIPARIAN BUFFER NOTIFICATION FORM
4[
i-! _�2. L� I + 'e oun1 r -
T
Stare ---
�' LC� Sig"
^se inc' design described in your application. Impecs not indlcatpd in the
ri,� Buffer R`{ ule. Site specific work should be provided in the application. [15A NCAC
r 0iQ � 01
:,e rarnoved 7-rorn Zone 1 of the Buffer (within 30 ft of the full pond elevation), unless
' �:. ' : •mac. it�u. �re;a�erel j uouermined along the immediate Shoreline can be removed,
irrirtieuiate 5norellne is allowed. [15A NCAC 028 .0243(6)]
got allowed. Excessive disturbance of ground coven [15A NCAC 028 ,0243 {6)]
LI.A, i=„Nzivua.,, wa4ways, etc. are not allowed in the buffer wnles5 specifically approved
1r„iation on size for decks, [15A NCAC 028 .0243(4y and {6)1
3,L, i 't„a;cate an ac.:,=ss and indicate any trees chat are to be removed. the
1 _r_scrit:ed. The approved access corridor shall be restored. Staging, spoil, construction
SA +.CAC 02,, .342 and 15A NCAC 023.0243 So), (6). (S)]
•�"� ' ••�:.•.: :'"?d or channeled for direct discharge to the lake. All constructed stormwater
r ,neural eiava.ion and disctiarged prior :o entering the ❑a;fer direcieb as diffuse or
.•,; -E,� -LF.r :ake. 115A NCAC 028 0243(5), i6ij
J� v' ► �� er<b+� state that I hive been infor:riad of the Catawba
3 i:, 'he bo.1t., not specifically stated in the a lication and a roved
PP p{�
r ie, ources (DVJR), is a violation and subject to enforcement. Due diligence will be
gill we built within substantial compliance and intent of the 401 Water
1A.;-,terPules.. the approved pian(s) and specification(s), and other supporting