Kulynych, Daniel

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CAMA IN DREDGE & FILL 0
GENERAL PERMIT Previous permit #
ISINew ElModification El Complete Reissue ElPartial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environment and Natural Resources
and the Coastal Resources Commission in an area of environmental concern pursuant to I SA NCAC t J 7
ELI Rules attached.
f-pplicant Name I T Project Location: County
dress Street Address/ State Road/ Lot #(s)
one # c:',
Affected
AEC(s):
ORW:
-' LStatei'41 ZIP
y. Fax #
DCW AJEW .0PTA -DES P PTS
0 OEA 0 HHF El 1H 0 UIBA / El N/A
0 PWS: El FQ
yes / no. PNA yes /. ri'o",,
Type of Project/ Activity
I IPier —
Pl:tf.
Fing-
Groi
'i
Ili
Basi
Boat
Boat
Beac
Oth �-
Sho
iSAV:
i Sandi
'Mo
hot
Crit.Halb. yes /, no
Subdivision
City —
ZIP
Phone
ho # River Basin
Adj. Wtr. Body("o (nat ft;an''/unkn)
Closest Maj. Wtr. Body . � 1
(Scale:
!h
,rpier(�s):
: mber
.ea� Riprap length
CV
_��jdistance offshore
max distance offshore
channel
cubic yards■■■■■■■■■■■■■■■■�i■■■■i■■■■■�■■e■■�■■■�■i
ramp
�,ouse/Boatlift
Bulldozing
r
"Length
line IMMMEME
MENNEN
MEMO
ii■■■■■■■■o
0
not sure yes 'no,
�ags:: not sure I "s
0■EMU
A building permit may be required by: ❑ See note on back regarding River Basin rules.
Notes/ Special Conditions
Agent or Printed Name PermitpfficersS Sign
ature
/177
Signature` Please read compliance statement on back of permit Issuing Date' r E piration pate
'Application Fee(s) Itheck# Local PlanningJ I urisdictionRoverFileNamel.%,

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 consistentwith the North Carolina Coastal Management Program.
River Basin Rules Applicable To Your Project:
Tar- Pamlico River Basin Buffer Rules 0 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 complywith 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: [phone]
Morehead City Headquarters,
400 Commerce Ave
Morehead City, NC 28557
252-808-2808/ 1-888-4RCOAST
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

AGENT AUTHORIZATION FORM FOR PERMIT APPLICATIONS
Name of Property Owner Applying for Permit: LZ Kdq Ai C&
Mailing address:
Telephone Number:
I certify that I have authorized M ea 4 )1411 ���agengcontractor),
to act on my behalf, for the purpose of applying and obtaining all CAMA ermits
necessary for the proposed development of � &W44'� , -4 CK
at my property located at 6 J
�low� fir
►4�5' —
This certification is valid through (date).
(Property Owner Information)
v
1 Sig
U
&- 14i fiy Alftl-
�l
Print or Type Name
Title, co. ownerrstee for property RECEIVED
MAY 2 0 2015
ate
Telephone Number
Email Address

DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION FORM
CERTIFIED MAIL - RETURN RECEIPT REQUESTED
I herebycertify that I own property adjacent to 1 Llitt'-1, 141(-y"Izek 's
fY N N Y
-_r a e of Property Owner)
property located at
(Address, Lot, Block, Road, e
on \./' �'�'r " , in , N.C.
(Waterbody)
Agent's Name #:
Agent's phone #:
(City/Town and/or County)
Mailing Address:
He/She has described to me as shown below the development he/she is proposing at that location,
and I have no objections to the proposal.
--------------------------------------------------------------------------------------=------------------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
If you have objections to what is being proposed, you mustnotify the Division of Coastal Management
(DCM) in writing within 10 days of receipt of this notice. Contact information for DCM offices is
available athttp://www.nccoastalmanagement.netlweb/cm/staff-listing orby calling 1-888-4RCOAST.
No response is considered the same as no objection if you have been notified by Certified Mail.
(Property 0 fo ati r
`U /
Signature {
)( 4
Print or Type Name
17 dN Ce" /Z#
Mailing Address
�Zfav�ir''�G
City/State2ip
Telephone Number/Email Address
s-7 Q2
Date
h
(Riparian Property Owner Information)
e
Aram; CAor
Prinror Type Name
RECEIVED
W" C4- MAY 2 0 2015
Mailing Address
PC— Y5st►" --MmEh C:17Y
City/Sta e2ip
a5..- a-f I - S 3
Telephone Number/Email Address
Date
(Revised: Aug. 2014)

I hereby certify that I own property
property located at 0 5/
on
0
Ilacent to
L 61) Giew
(Address, Lot,
in
e of
N yc f ,S
ner)
-- 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)
`T7-�� l�c�--w,nsl�i,"��Z C��2 �1g-�1 �t..i �' �otisl' � � �� i 1 inn w•6-�
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.)
do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Propert wn fI mation) (Adjacent Property Owner Information)
WW
Signature �I+J(X
Print or Type Name SO OL4
C&Mt
Mailing Addrfs .. #V� / f�vJ'
City/State/Zio
TelephoneNu�a�er/emil+ ddress
Date
*Valid for one calendar year after signature*
Print or
Date *
(Revised Aug. 2014)
RECEIVED
MAY 2 0 2015