27074_BROSS, ROMMIE_20010109

y
CAMA and DREDGE AND FILL
G E N E R A L�'�74 �
P E R M I T
as authorized by the State of North Carolina { r /� t
Department of Environment and Natural Resources and the Coastal Resources Commission
in an area of environmental concern pursuant to 15 NCAC
Applicant Name
Address
City
i 1 L•J "1 t
State
Phone Number
Project Location (County, State Road, Water Body, etc.) , ( <' i
zip
Type of Project Activity '' l,. P, c' ;,' - �;'� l' °T " a� new �,,, �•.L l�
and attacneci general ana specmc conamons. Hny viola❑on of inese terms
may subject the permittee to a fine, imprisonment 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 of-
ficer when the project is inspected for compliance. The applicant certi-
fies by signing this permit that 1) this project is consistent with the local
land use plan and all local ordinances, and 2) a written statement has
been obtained from adjacent riparian landowners certifying that they
have no objections to the proposed work.
In issuing this permit the State of North Carolina certifies that this project
is consistent with the North Carolina Coastal Management Program.
applicant's signature
r-
permit officer's signature
issuing date
expiration date
attachments
application fee

1866
ERIC B. ELLIS NCDL 65047
JASA M ELLIS PH(252)726-6775 65-30/531
205 NOMNGHAM DR. 6E 133
MOREHEA,D C/fTY, NC 28557 Date
Pay to the �N j $
Order of--- ••w•
r Dollars•
FYRSI CITIZENS,3328512
[
��7/>7�
For l ��� O L 8 6 6
i:0 5 3 L00 300,:00 L 3 L 7 448 780
GUARDIAIJ® SAFETY BLUE ESBL
Oi'INk[RIM[I1C na

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIERIMOORING PILINGSIBOATLIFT/BOATHOUSE)
I hereby certify that I own property adjacent to b nr m i�� (-,rn rS 's
(Name of Property Owner)
property located at fif ;�; „V '0 ,
(Lot, Block, Road, etc.)
on �„i , in ' f i C , 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 waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
V V --
a�K
zlxrk-
------------------------------------------------------- u--'--------------------- ---------------
17,
Signature f
`%. L . 14 EgRI
Print or Type Name
252-- 2qJ- 1141
Telephone Number
Date: ! Z-1 /8 /O0

ADJACENT RIPARIAN PROPERTY OWNER STATFAIENT
(FOR A PIERIMOORING PILINGS/BOATLIFT/BOATHOUSE)
I hereby certify that I own property adjacent tos s
(Name of Property Owner)
property located at
(Lot, Block, Road, etc.)
on � rb in ZLI� ,,,,4r c F , 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 waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
Signature
Print or Type Name
Telephone Number
Date: f o