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Application Fee(s) CTeck# Local Planningjurisdictioti--
i Date
i Name
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 I) 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 consistent with the North Carolina Coastal Management Program.
River Basin Rules Applicable To Your Project:
F1 Tar - Pamlico River Basin Buffer Rules 71 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
Mailing Address:
1638 Mail Service Center
Raleigh, NC 27699-1638
Location:
2728 Capital Blvd.
Raleigh, NC 27604
919-733-2293
Fax: 919-733-1495
Morehead City Headquarters.
400 Commerce Ave
Morehead City, NC 28557
252-808-2808/ 1-888ARCOAST
Fax: 252-247-3330
(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:252-264-3723
(Serves: Camden, Chowan, Currituck,
Dare, Gates, Pasquotank and Perquimans
Counties)
Washington District
943 Washington Square Mall
Washington, NC 27889
252-946-6481
Fax: 252-948-0478
(Serves: Beaufort, Bertie, Hertford, Hyde,
Tyrrell and Washington Counties)
Wilmington District
127 Cardinal Drive Ext.
Wilmington, NC 28405-3845
910-796-7215
Fax:910-395-3964
(Serves: Brunswick, New Hanover,
Onslow -below New River Inlet- and
Pender Counties)
Revised 08/09/06
s - �
Applicant;"
Date: lot
F
✓ 1
Describe below the HABITAT disturbances for the aPP .. lication. All values should 4fiatc the name and units of measurement
found in your Habitat code sheet.
C
Habitat Name
DISTURB TYPE
Choose One
TOTAL Sq. Ft.
(Applied for.
Disturbance•total
'Includes any -
anticipated
restoration or
to s)
FINAL Sq. Ft.
(Anticipated final
disturbance.
- Excludes any-
restoration
and/or temp
im a am nt)
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 ❑ Fill Q Both ❑ Other
Dredge ❑ FIW❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both' ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑ .
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ . Fill ❑ Both ❑ Other ❑
Dredge ❑. Fill ❑ Both ❑ Other ❑
revised. QW0,3110
s
Pat McCrory
Governor
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Braxton C. Davis
Director
Date �(Ir. �) , 2-v 1 q
Applicant Name )7L,; ,. 7
Mailing Address ;f -' 5;�-
_lL,smare rh PA 19067e-I
John E. Skvarla, III
Secretary
I certify that I have authorized (agent) 1>e'V-% ` M,-r,nC (cs to act on my behalf, for the
purpose of applying for and obtaining all CAMA Permits necessary to install or construct (activity)
re_F ac'_,� c' �`ss= n� d,;LIL 'c� (`� ee&( (. , at (location)
,� 3 �5 •• tie- d Ic.,-i-. (3eclL tv
This certification is valid thru (date) SC.' 3, Z
lam__ A Ir
Signature
400 Commerce Ave., Morehead City, NC 28557
Phone: 252-808-28081 FAX: 252-247-3330 Internet: www.nccoastaimanagement.net
An Equal Opportunity 1 Affirmative Acton Employer
NorthCarolina
Na lrallr�
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
hereby certify that I own property adjacent to S--Oar-�- G ; r-OJ X 's
(Name of Property Owner)
property located at ,�3 1 k-:�S-1-e.- (�vC
(Address, Lot, Block, Road, etc.)
on a ,, �� , in 0+V,,V. c T3eac(, , N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
uy�d\have=noobjection-tot ih s ro osal
gyp, • k• _��p p -
X 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)
S ee a. WcXeJ draL-� I rl'S
_JAN 16 2014
M.
�, � ACNI-MHD CTiY
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
y� wish -to waive the setback, you must initial the appropriate blank below.)
d:lcLwish=to:waive-the=-15�setback_cequicemsnt,
k
I do not wish to waive the 15' setback requirement.
(Property Owner Information) (Adjacent Property Owner n
Signature nature
Print or Type Name Print or Type Name
Mailing Address Mailing Address
i4 1 t�y by ¢� le�,�� ry (- 2-7 611
City/State/Zip City/State/Zip
ol11--7- 97�
Telephone Number rTelephon Nu ber
Date '4,bate
(Revised 611812012)
-ftj,oYJ
O Q
0
��c7u�cJ ia••-�--. v
19
J
• ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to SJ, Lkw4- 's
(Name of Property Owner)
property located at 5 3 A'i e-
(Address, Lot, Block, Road, etc.)
on 13oose Sd� , in +1�-�:� �3cGcl.. , N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
loc i�
r1`have nn=a3bj6cionfosthis 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)
�:y,# _ itECEIVkn
JAN 16 W4
WAIVER SECTION
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
r wish -to waive the setback, you. must initial the appropriate blank below.)
��`s r�dow�sli��waiYe, he_,15 setback -requirement:
• 4
a-v I do not wish to waive the 15' setback requirement.
(Property Owner Information)
Signature
S�xiri- �; �oyX
Print or Type Name
Mailing Address
(J47c-r-� Qa l(�y
City/State2ip
ItgLf - 3,5 ?- 7 9 2 l
Telephone Number -
�� to , Zv t4
Date
�Af_?
Information)
Print or Type Name
�D v � bL�tl.Jood C�4 .
Mailing Address
(?-mot e' <�, fU C— 2-:7 6 t `7
City/State2ip
M/ -- Wnl- 3635
� TeleptnNumber
` Date
(Revised 611812012)
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