Everett, Scott

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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, certifythat this project is consistent with the North Carolina Coastal Management Program.
River Basin Rules Applicable To Your Project:
El Tar- Pamlico River Basin Buffer Rules
0 Neuse River Basin Buffer Rules
El 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 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 howto complywith 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

ME
f,Mc 1,K,',,9,F75-,j3FE.:�.? Q
k
Applicant:
Date:
Describe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
found in your Habitat code sheet.
Habitat Name
DISTURB TYPE
Choose One
TOTAL Sq. Ft.
(Applied for.
Disturbance total
includes any
anticipated
restoration or
temp impacts)
FINAL Sq. Ft.
(Anticipated final
disturbance.
Excludes any
restoration
and/or temp
impact amount
TOTAL Feet
(Applied for.
Disturbance
total includes
any anticipated
restoration or
temp impacts)
FINAL Feet
(Anticipated final
disturbance.
Excludes any
restoration and/or
temp impact
amount)
Dredge [I Fill Both' El Other D❑.9
)
—7
"
Dredge El Fill'El Both [I Other 0
Dredge El Fill [I Both El Other El
Dredge El Fill [:1 Both [I Other [I
Dredge [I Fill [I Both El Other El
Dredge El. Fill El Both El Other M
Dredge El 171 Both El Other [1
Dredge El Fill 171 Both D Other D
Dredge [I Fill [I Both El Other ❑
Dredge El Fill El Both E❑I Other El
Dredge 0 Fill El Both El Other El
Dredge [I Fill El Both El Other El
Dredge 171 Fill El Both [I Other [I
Dredge D Fill El Both 0 Other r7I
Dredge 0 Fill El Both [I Other El
i -fv . 4,18. dh i1'22M'131-1,

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date
Name of Property Owner Applying for Permit:
Mailing Address:
I certify that I have authorized (agent) C,(� �--� �6� 5��� �- to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity) � Q W 8 C1
at (my property located at)
This certification is valid thru (date)
�( 112- Wr3
Prop rty Owner Signatur Date
. Il�Glrli/E1�
APR 12 2013
DCM MHD CITY

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
hereby certify that I own property adjacent to"tiJe�c2. a "�; �'� 's
2 property located at (Name of Property Owner)
� �?`��ell� �-�- ,
(Address of Bloc Road �3 etc)
on A , in k 1 zk*�\L bC A C�N , N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location.
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must rill in description below or attach a site drawing)
rcp)Ac, 12.22 o � bulk �,c1
APR 12 2013
sco t oi-
DCM-Mff DCff
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set
back a minimum distance of 15' from my area of riparian access unless waived by me. (If you
wish to waive the setback, you must initial the appropriate blank below.)
r ?1 I do wish to waive the 15' setback requirement.
(P
I do not wish to waive the 15' setback requirement.
SC
Print or Type ame / f
Date
YL
(Adjacent Propertj/yam Owner Information)
Signature , in t'I _ Bc�c K w • �'�
Print or Type Name
/// (e to,--,), /?J
Mailing Address
ki: / 1 , Jt/ C a,7 5
City/State/Zip
Telephone Number
-_J7 _ )3
Date
(Revised 611812012)

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
hereby c1rtfy that I own property adjacent to �' •r ��' L ~ `� ^ ` °s
y, (Name of Property Owner)
property located at � 3 � ��l�J el/� 5� ,
(Address, dot, �Iocl��oad, ;etc.)
on 'A rv- in r}-�0, \1C, VeQkc , N.C.
(Waterbody) (City/Town and/or County)
The �IQ�;
nt has described to me, as shown below, the development proposed at the above
loc t
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(individual proposing development must fill in description below or attach a site drawing)
rcp)Ac, 12-22 o � bL,l 0h -,a
Imo..
I UCEWED
PR 12 2013
:-CXD rr OA - CUeMRDCUY
WAIVER SECTION
1 understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set
back a minimum distance of 15' from my area of riparian access unless waived by me. (If you
wish to waive the setback, you must initial the appropriate blank below.)
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
.S2�
Print or Type ame l
n / / eA 41, , 1%!
Mailir� Address
CityCity/State/Z r�-
qi��G�- 0 0 2-
Telephone Nu er
Date
(Adj ent Property Owner I o ation)
s
173
d ' 4
Print O Tw� Nam
Ma' i g Address , C-
City/State/Zip
1� 52-
Telephone Iyumoer
y �13
Date
(Revised 611812012)