20150900 Ver 1_IP Adjacent Property Owners 9-2015_20150903

24. Is Any Portion af the Work Already Complete? ❑Yes �X No IF YES, DESCRIBE THE COMPLETED WORK
� 25. Addresses af Adjoining Property Qwners, Lessees, EtC., Whose Property Adjoln5 the Wat2t'6ody {ifi more ihan can be ernered here, please attach a supplemental list�.
I a. Address- L1.S. National Park Service - Cape Hatteras �lationa] Seashore 1401 National Park Drive
City - Manteo
b. Address-
City -
c. Address-
City -
d. Address-
Ciiy -
e. Address-
Ci1y -
State - NC Zip - 27954
State - Zip -
State - Zip
Siate - Zip -
Sfate - Zip -
Lis# of Other Certificates or Approvalsl�enials received from other �ederel, Staie, or Local Agencies for Work described in This Application.
P.GENCY TYPE APPROVP,I." I�ENTIFICATION DATE APPLIE❑ �ATE APPROVEL DATE ��NIED
NUMBER
Vlajor Permit �'tod. 224-87 911f2015 91]/2Q15
Individual Permit 9I112015
" Wauld include but is not restricted to zoning, building, and flpod plain permits
27. Applic�tipn is heret�y made for permit ar permits tt� auihorize ihe work described in this application. I eertify that this information in this appiicaiion is
co€nplete and ac urate. I further c.�r[ify that I possess the authority to undertake the work descri�ed herein or am acting as #he duly authorized agent of the
applic t.
� q r i,r-
SIGNATURE OF APPLICANT � E SIGNATUR� OF AGEN"C DA7E
The ApplECation must be signed by the persan wha desires ta undertake the proposed aetivity (applicant) or at may be signed by a duiy
authorized agent if the statement in block '! 1 has taeen filled out and si�ned.
i 18 U.S.G. Sectio� 1001 provides that: Whoever, in any manner within the jurisdickion of any department or agency of the lJnited S�ates
knawingly and willfulfy falsifies, conceals, ar covers up any trick, scheme, or disguises a material fact or makes any false, fictitious or
fra�duPent statements or representatians or makes or uses any false writing or docurnent knowing same to contain any false, fictitirsus or
fraudu€ent statements or entry, shall be fined not more than $10,440 or imprisoned nai more than five years or bath_
ENG FORM 4345, OCT 2012
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