59319_ROSSI, JEANNIE_20111024

❑CAMA / ❑ DREDGE & FILL ►+
GENERAL PERMIT Previous permit #
❑New ❑Modification ❑Complete Reissue El Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environment and Natural Resources
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
❑ Rules attached.
Applicant Name t '• j Project Location: County
r
Address /' {'. Street Address/ State Road/ Lot #(s)
11 �.
'.;' b'
City
State ZIP
Phone # O
- Fax # O
Authorized Agent
Affected ❑ CW
❑ EW ❑ PTA ❑ ES ❑ PTS
AEC(s): ❑ OEA
❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS:
❑ FC:
ORW: yes / no
PNA yes / no Crit.Hab. yes / no
Subdivision
City ZIP
Phone # ( ) River Basin
Adj. Wtr. Body (nat /man /unkn)
Closest Maj. Wtr. Body
Type of Project/ Activity
(Scale:: )
Pier (dock) length
Platform(s) Ilk
Finger pier(s)
Groin length
number
Bulkhead/ Riprap length ' !(•
avg distance offshore
max distance offshore f
Basin, channel
-
t
I
,
o
cubic yards
Boat ramp
Boathouse/ Boatlift
_
_
t
t
Beach Bulldozing46
Other
-
--
-
Shoreline Length
SAV: not sure yes no
Sandbags: not sure yes no
Moratorium: n/a yes no
Photos: yes no
Waiver Attached: yes no
A building permit may be required by:
Notes/ Special Conditions
0 See note
on back regarding
River
Basin
rules.
Agent or Applicant Printed Name
Signature ** Please read compliance statement on back of permit t
Application Fee(s) Check #
Permit Officer's Signature
Issuing Date Expiration Date
Local Planning Jurisdiction Rover File Name
r

I
Statement of Compliance and Consistency
This permit is subject to compliance with this application, site drawing and attached general and specific conditions. Any
violation of these terms may subject the permittee to a fine or criminal or civil action; and may cause the permit to become
null and void.
This permit must be on the project site and accessible to the permit officer when the project is inspected for compliance. The
applicant certifies by signing this permit that 1) prior to undertaking any activities authorized by this permit, the applicant will
confer with appropriate local authorities to confirm that this project is consistent with the local land use plan and all local
ordinances, and 2) a written statement or certified mail return receipt has been obtained from the adjacent riparian
landowner(s) .
The State of North Carolina and the Division of Coastal Management, in issuing this permit under the best available
information and belief, certify that this project is consistent with the North Carolina Coastal Management Program.
River Basin Rules Applicable To Your Project:
❑ Tar - Pamlico River Basin Buffer Rules ❑ Other:
❑ Neuse River Basin Buffer Rules
If indicated on front of permit, your project is subject to the Environmental Management Commission's Buffer Rules for the
River Basin checked above due to its location within that River Basin. These buffer rules are enforced by the NC Division of
Water Quality. Contact the Division of Water Quality at the Washington Regional Office (252-946-6481) or the Wilmington
Regional Office (910-796-7215) for more information on how to comply with these buffer rules.
Division of Coastal Management Offices
Raleigh Office Morehead City Headquarters
Mailing Address: 400 Commerce Ave
1638 Mail Service Center Morehead City, NC 28557
Raleigh, NC 27699-1638 252-808-2808/ 1-888-4RCOAST
Location: Fax: [phone]
2728 Capital Blvd.
Raleigh, NC 27604
919-733-2293
Fax:[phone]
(Serves: Carteret, Craven, Onslow -above
New River Inlet- and Pamlico Counties)
Elizabeth City District
1367 U.S. 17 South
Elizabeth City, NC 27909
252-264-3901
Fax:[phone]
(Serves: Camden, Chowan, Currituck,
Dare, Gates, Pasquotank and Perquimans
Counties)
Washington District
943 Washington Square Mall
Washington, NC 27889
252-946-6481
Fax: [phone]
(Serves: Beaufort, Bertie, Hertford, Hyde,
Tyrrell and Washington Counties)
Wilmington District
127 Cardinal Drive Ext.
Wilmington, NC 28405-3845
910-796-7215
Fax:[phone]
(Serves: Brunswick, New Hanover,
Onslow -below New River Inlet- and
Pender Counties)
Revised 08/09/06

JEANNE ROSSI
7 HEIDI LANE
MOUNT SINAI, NY 11766-1428
------- - -----
2111 w
50-8118/2214
Llo,�(� 7air
Vag to tl(r .' 1 11 'j,v ` J 1
(I hrr of / l
SUFFOLK FEDERAL
T CREDIUNION
3681 Hombimk Road
U Medford, Boxord sons
��QQMedford,9005 do ll'76,3(I.
1:22148LLBLl:LL4L0005834E071102L, L

ADJACENT RIPARLV1 PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSIBOATLIFT/BOATHOUSE)
I hereby certify that I own property adjacent to _ rXANN/ 1. is
(dame of Property Owner)
property located at _ 1 �Ly popy e,7-
(Lot, Block, Road, etc.)
on /NiirvIt X,,AA- , in ('Cwxm' �SAvag) , N.C.
(Waterbody) (Town and/or County)
He has described to me, as shown below, the development he is proposing at that location,
and, I have no objections to his proposal. I understand that a pier/mooring pilings/boatlift/boathouse
must be set back a minimum distance of fifteen feet (15') from my area of riparian access unless
waived by me.
I do not wish to waive the setback requirement.
✓ I do wish to wa4that setback requirement.
---------------------------------------- �--7
AND/OR DRAWING OF PROPOSED DEVELOPMENT;
(To be filled in by individual.proposing development)
fj i'':tA
ma
Nk ok Av>qa-
(Applicant Information)
Mailing Address
A Ari417 f j y 1, Al-
City/State2ip
G / 33�C_ 5R/
Telephone Number
ID -Z1 /J
P9r#O
---------------------------------------------------------
'pa ian P nner Information)
Signature
Print or Type Name
z,S-z 72.S__ /7�3�
Telephone Number
// C� ell
Date Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/IbI00RING PILIIYGSIBOATLIFT/BOATHOUSE)
I hereby certify that I own property adjacent to �) fo-Y1 n
' 's
(Name of Property Owner)
property located at t a v Q o!y c;r
(Lot, Block, Road, etc.)
on 4/ P (A S L � I i e y , in C V- C- J if C V Lt_V\- , N.C.
(Waterbody) (Town and/or County)
He has described to me, as shown below, the development he is proposing at that location,
and, I have no objections to his proposal. I understand that a pier/mooring pilings/boatlift/boathouse
must be set back a minimum distance -of fifteen feet (15') from my area of riparian access unless
waived by me.
I do not wish to waive the setback requirement.
JI do wish to waive that setback requirement.
---------------------------------------------------------------------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individualproposing development)
ea,,a W01, llhe4 04f— j(4P t A- )j¢rvj -rP -*i
�,t,Ii ✓3, /4Pit if—
---------------------------------------
(Applicant Information)
Mailing Address
City/State/Zip
Telephone Number
to ,21- /i
Dale
Ask"
(Riparian Property Owner Information)
Signature
Yi //,14 ,1 �q l Z., 1 v
Print or Type Name
2- -GGS-0S /D
Telephone Number
Date

10/24/2011 11:21 631-853-2350 SCDDHDSCSN PAGE 01/02
OF HEAi..T'H SERVICE'S
COUNTY OF s.UFFOL
ST'EVE LeVy
SUFFOLK COUNTY FXECU7'1VE
FAX COVER SHEFT
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JAMES L. TOR VARK&S, MD
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Comm1 E ioner
BUREAU OF SERVICES FOR CHILDREN i! trH SPECIAL NEEDS
SA (Laser Court Hauppeu9e, NY 11788 [phone] Fax (631) 863�2300
The information contelned In this facaimlle measa���'� •
the uae of the iddritses named above. ►spa!!y. prlvhe Int and recidtentiaf Information Intandel! only for
dIRssmination dI If the render of this Is not the )nhnded reclRlent, you mrs hereby notifig cl (hat an
immedlstel no shibutian ar copy of this tee the is strictly prohibltRd: If YOU rrwoetyi this talecopy !n error, pl a toe
�► l ua by telaphorte and rriturr� the orljjInsl rgssas9a to ue at fho mdelN�e .a.,,«....�... w ,....,
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10/24/2011 11:21 631-853-2350
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