Bader, Robert

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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, certifythatthis project is consistentwith the North Carolina Coastal Management Program.
River Basin Rules Applicable To Your Project:
❑ Tar- Pamlico River Basin Buffer Rules
❑ Neuse River Basin Buffer Rules
❑ Other:
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 Resources. Contact the Division of Water Resources at the Washington Regional Office (252-946-6481) or the
Wilmington Regional Office (910-796-7215) for more information on how to complywith these buffer rules.
Division of Coastal Management Offices
Morehead City Headquarters Washington District
400 Commerce Ave 943 Washington Square Mall
Morehead City, NC 28557 Washington, NC 27889
252-808-2808/ 1-888-4RCOAST 252-946-6481
Fax: [phone] Fax: [phone]
(Serves: Carteret, Craven, Onslow -
North of 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)
(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 - South of New River Inlet -
and Pender Counties)
http://www.nccoastaimanagement.net/
Revised 08/27/ 14

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AGENT AUTHORIZATION FORM FOR PERMIT APPLICATIONS
Name of Property Owner Applying for Permit:
Mailing address:
Telephone Number:
G
I certify that I have authorized A (agenttcontractor),
to act on my behalf, for the purpose of appijVng and obtaining all CAMA permits
necessary for the proposed development of _PKAnvq . 411J
at my property located at /
This certification is valid through 3 (date).
(Property Owner Information)
Sign ture
Print or Type Name
Title, co. owner or trustee for property
16` Z
Date
aI ny 1
Telephone Numb r
e !/t
. Email Asl[dress�—
RECEIVED
FEB 2 0 top
DCM- MHD CITY

. r ,-�ma I y OWNER STATEMENT
I hereby certify that I own property adjacent R�,.
grope located at / , Name Of rope4 ®weer) 's
(Ad ress, Lotlock, a tc.)
OftfaterbodY) in _ ` k -
� tyli'awn and/or County) N.C.
The applicant has described to me, as shown below, the development proposed at
EN* -
the above
1 have no objection to this proposal.
------- I have objections to this prop saL
DESCRIP t ION AND/OR DRAwINC OF PROpO�Ei3 L?E=i/Ei (� ENIp °
(Individual Proposing development must Ii 1 i
lion below or aft
swing)
I understand That a pier, dock, mooriWAIV ng CT O �
must be set back a minimum distance of 15' from my area at�ipa an access
tft, or groin
me. (If You wish to waive the setback, you must initial the appropriate blanks unless waived by
d
I do wish to waive the 15' setback requirement
------_ I do not wish to waive the 15' setback requirement.
Froperzy Owner information)
(Adjacent Pr e , 9P rty Owner information)
Te! one NU. he temall
Dates D
Print�p
----.�
c
Marling Ad
-
Date*
RValid for one calendar year after signature*
�,Tl
% Jam% RECEIVED
I, errgad address
FEB 2 0 2017
{Revised Aug. �-

CAA
! hereby certify that 1 own
property
adjacent ` Name
4
props located at ( .� , J�iatns of . ropers a 's
Owner)
(Ad Tess
v� , tao • � ck, a� fo.}
(utfattr�tdyj to
( W town andior County) N.C.
The applicant as described to me, �5 5Jiol�ln below, the development Proposed Ioca�i p 1 have no objection to this proposal. p d at the above
! have Objections to this Dronosal
AND/OR DRAWING Di° pR pOSED �i_P!�
(Irld dualPrOPOSrr�g development must fife in x�ls's1Eib.D
¢���:��3,.M NT
c
R4CEIVED
FEB 2 0 2017
ACM- MHD CIT
�� ! understand that a pier, dock, mooring pilin s
must be set bac!< a minimum distance of 15` from my p' hreaeTi boathouse, t ", or groin
me. (if you i
sh to waive the setback, you i?usi !Witte! the appropriate blanks unless Waived by
do wish to waive the 15' setback requirement �
! do not Wish to w • ih
aive a 15 setback requirement.
(I:"'-70wner Inror►nattarr)
Date
4 " 7
J
TIC
aLJ
'
1 1 it
'Valid for one calendar year after signature°