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iv kiK i n k AJCULLN A LN D USZTR.IAL COMMISSION 4 <br /> I.C. FILE NO. T- ' <br /> N.C. PRISONER NO.- <br /> RALEIGH (I[applicable <br /> CLAIM FOR DAMAGES UNDER TORT CLAIMS ACT, G.S. 143-291 et. seq. <br /> STATE OF NORTH CAROLINA <br /> AFFIDAVIT <br /> COUNTY OF ORANGE <br /> Lawrence J. Noe , being duly sworn, deposes and says: <br /> (rnn Nr a ch;..a <br /> 1. That his/her name is Lawrence J. Noe, <br /> 2. That he/she lives at 5209 Piney Hollow. Durham, NC 27705. <br /> and that his/her mailing address is Lame as above. <br /> 3. That he/she hereby files a claim against State of North Carolina Deo�e,nt of Environment Health & Natural <br /> Resources, Division of Environ_MSa1 Management (3ww Ag.ry er CMW 9-4 d 5b"W <br /> and that its mailing address is 512 N. Salisbury St.. Raleigh. NC <br /> for damages resulting from the negligence of See Exhibit A <br /> (PM Hr e(8wrigw w Apo bwdw* <br /> 4. That he/she has been damaged in the amount of S See Exhibit A by reason of the negligent conduct of the employee <br /> agent named above. <br /> 5. That the injury or accident giving rise to this claim occurred at .Pi= Mountain subdivision_ Otange Coun <br /> on 19,_„_, at M. <br /> t That the injury or property damage occurred in the following manner: <br /> (Giw&W&MMM 1 Wre N ri.lirr et Rrirw� +e.) <br /> The Claimant is an owner of lot 30 and has a home oetha_t lot served bX the community^sewer system in the Piney <br /> Mountain subdivision The Claimant has been damag2d by the actions of DEM in the manner described in Exhibit A. <br /> (Claimant owns the lot iointil with his wife. Susan Y. Noe.) <br /> 7. That the damages claimed above consist of the Claimant's cots in reoirin!an%r rlplacing the sewerage system an <br /> expenses of investigating how to mitigate this damage. <br /> IN TESTIMONY WHEREOF, the said Lawrence 1. Noe has hereunto set <br /> his hand and seal, <br /> (N. of chw" <br /> this day of '"nOWAY1,601 . 19_U <br /> i worn to before me :�--�-- 1. J <br /> Subscribed and �... <br /> this day of 1 <br /> JzmW <br /> 36 er Newry tiw+ <br /> My Commission Expires <br /> FILE FOUR COMPLETE COPIES Wli INDUSTRIAL COMMISSION <br /> (Lr admaw of+wee-.n.r.rMd--2 ago" <br /> Set MWW re et rom rw to"board rw <br />