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, C�►'1K11A1 ❑ OVIE GE & F,ILL
A B D
kNERAL PERMIT
Previous permit #
New ' ❑Modification ❑Complete Reissue ❑Partial Reissue
Date previous permit issued
As authorized, by the State of North Carolina, Department of Environment and Natural. Resources
Resources Commission in of concern I SA NCAC
and the Coastal an area environmental pursuant to
❑ R les attached.
' Project Location:
Applicant Name j
ty _,
Coun. y
Address ,r %�
'' ,l Street Address/ State
Road/ Lot # s
City
r State ZIP
Phone # O E-Mail 'Subdivision
Authorized Agent ct` 'h f d1'I City
'' ZIP
Affected Gw W APTA ❑ ES ❑ PTS Phone # ( )
River Basin
❑ OEA ❑ HHF ❑ IH ❑ USA ❑ N/A
AEC(s): ' Adj. Wtr. Body
A-"It2
i (nat f%ma nunkn)
❑ PWS:
ORW: yes / o PNA yes / Closest Maj. Wtr. B I
Type of Project/ Activity o' F f } °, c d
Pier Nock
Fixe
Floa
Fing,
Groi
Bulk
Basil
Boat
Boat
Beac
Othi
Shor
SAV
Mor
Phoi
Wain
(Scale:" ; )
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- regarding River rules.
A buiit may
( Note Local Planning jurisdiction)
Notes/ Special Conditions
1 . 1..
"•r.d 0A)l A I
1 �� "�
i f'
J'il k r
Age or Applicant Printed'Name
Permit Officer's Printed
Sig r Please read compliance statement on back of permit
/� f
Signat e
.p 3
Application Feels) Chetk#
Issuing'
E'pration ate
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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, 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 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 comply with these buffer rules.
Division of Coastal Management Offices
Morehead City Headquarters
400 Commerce Ave
Morehead City, NC 28557
252-808-2808/ 1-888-41RCOAST
Fax: 252-247-3330
(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: 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 - South of New River Inlet -
and Pender Counties)
http://www.nccoastaimanagement.net/
Revised 08/27/ 14
4A)m A`1 � MRE15113E & FILL
PERMIT
j
A B CD
.,.,.-."GENERAL
'CRY-]Complete
Previous permit #
Reissue ElPartial Reissue
New ElModification E Date previous permit issued
As_,author:izecl by the State -of North Carolina, Department -of Envir-onment and Natura6Qesources
-ar.id.-theCoastal Resources Cofnfhissiohi
ri-2ih;ireaofenViebhhii�ntAlconcerffoLjrsuanttb'[SXNCAC'
J�li
LJ Wes
Applicant Name pplican-
Project Location: County
Address
Street Address/ State Road/ Lot #(s)
City:;JA State ZIP
Phone# EMail
'Subdivision
Authorized Agent
k.
City 71P
f
0 CW R'6W APTA F1 ES El PTS
Affected
Phone # River Basin WA
El OEA 0 HHF El lH 0 UBA 0 N/A
AEC (s):
Adj. Wtr. Bod nat m a unkn)
0 PWS:
0 yes 01)
Q? PNA yes
Closest Maj. Wtr. Body
,TY-Pe df,P *ect/ Activity
Project/
(Scale: -'7 1
Bash
13ciat
.Beac
Othi
�$hor
SAV
Mor.
Phoi
Wain
Platform(s)
MEMNON■MEMMEMEMEMEMEMEM
7
5
ing,Platform(s)
ME
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MEN
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,Abuilding permitmaybe required by:
V f I
LJ See note on back regarding River Basin rules.
Note Local Planning jurisdiction)
'Motes/ Special Conditions
42
egg or App�,antrrintecl'Name
PermitOfficer's
Printed Nettie if
-e
PI ease read compliance statement on back of permit "l
Sig,ntaif0 Z
�
,iO
o e(s)
-Chei:k#
Issulng Dalet
E�iirationVate
Get your mail when and where you want
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Refunds for guaranteed services only
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840-5280-0271--001-00005-32643-01
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call 1-800-410-7420
Bill #: 840--52800271-1-532643-1
Clerk: 05
NEWPORT
337 HOWARD BLVD
NEWPORT
NC
28570-7929
3655440570
03/09/2017 (800)275-8777 1:27 PM
Product Sale Final
Description Oty Price
First -Class 1 $0.49
Mail
Letter
(Domestic)
(SUN CITY WEST, AZ 85375)
(Weight:0 Lb 0.70 Oz)
(Expected Delivery Day)
(Monday P343-/-2491_71.
Cert' 1 -`' 3.35
(@@LISPS Cer Tied Mail #>
(70160340000041498779>
Return $2.7
Receipt
(@@USPS Return Receipt #)
(9590940225606306686763)
Affixed 1 ($0.49)
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(Affixed Amouht:$0.49)
Total $6.10
Cash $6.10
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COMPLETE THIS SECTION A
■ Complete items 1, 2, and 3. A. Signature
■ Print your name and address7onthe reverse X�
so that we can return the card to you.
B. eceived by ted Name
■ Attach this card to the back of the mailpiece, �j or on the front if space permits.
1. Article Addressed to:
c'+a,� I•ey Sakmo5Y,% 13733 Ldee' k mt-egpD
jz,wr c � 0051 kz
85 3' 5
IIIIIIIIIIII)IIIIIIIIIIIIII (III III IIIII IIIIIII
9590 9402 2560 6306 6867 63
2. Article :Number (Transfer from service label)
7016 0340 0000 4149 8779
PS Form 3811, July 2015 PSN 7530-02-000-9053
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Is delivery address different fomitem 1? U Yes
If YES, enter delivery address below: p 'No
RECEIVED
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• Sendder—:.,P�l`ease .print yopur.narne, address, and ZIP+4® in this box•
t� .1&C eio 1 v :0 � 5, CO a+�
15 Gg lELA-)i 70 wesk SvI
N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date —( 3 1 7
Name of Property Owner Applying for Permit:
Mailing Address:
I certify that I have authorized (agent) Dgv; A Arde.rso., to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity) 40vk
�LL +
at (my property located at) �0S MtA1 bQ r� C.,T Pi.�t k^J ` S�0rt. s 1,1 (-
This certification is valid thru (date)
Property Owner Signature
RECEIVE
MAR 2 4 2017
/C,YI® MHF, gITY
Date
MAR 21 2017
DCM- MHD CITY
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Harrell IEZ Dock Solutions
Bill
PREPARED FOR 5568 Hwy. 70W,
Newport, NC
ORAW NG NUMBER TOLL FREE No. 252-764-1234
105
[C
PHONE NO.
DRAWN Br DA �3/8/17 252-648-8026
• t s
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to �i �� c• r�-� Is
r� (Name of Property Owner)
property located at �iru�Cnalk SG"Ovts agst a
ii (Address, Lot, Block, Road, etc.)
one �rnol` S�>`e5r�i , in 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 fill in description below or attach a site drawing)
RECEIVE®
MAR 21 2017
CITY
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, 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.)
RECEIVE"D
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Prope Owner ation)
Signature
Rd/
Prinrt)or Typ/e� Name L� /'�GrC,aOi
Mailing Address
C. A I d 7 S -1
Co&tarte/Zip
�91G) (::,( 8-q9ug
Telephon Nu ber/email address
l 7
Date
MAR 2 4 2017
(Adjacent Property O ner Inform2t- � M HE), 'CITY
.C�rrr,nt.rnk _
Print dr Tvpe Name
i10 > — Yi i— 7 s
Telephone Number/email address
Date's
P7
(Revised Aug. 2014)
*Valid for one calendar year after signature*
CO C
CO C
10
13
0
Harrell
_ N < EZ Dock Solutions
® o
PREPARED FOR 5568 Hwy. 70W,
ti Newport, N
DRAWING NUMBER
TOLL FREE No. 252-764-1234
PHONE N0.
DA DA3/8/17 252-648-8026