Matson, Paul

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:
❑ 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 howto complywith these buffer rules.
Division of Coastal Management Offices
Morehead City Headauarters
400 Commerce Ave
Morehead City, NC 28557
252-808-2808/ 1-888-4RCOAST
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)
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 - South of New River Inlet -
and Pender Counties)
http://www.nccoastaimanagement.net/
Revised 08/27/ 14

IT
Name of Property OVvner Requesting Permit: TOU-1 Ka�54-
Mailing Address: 6 5 3 ? Lo uc5e, -Ave-
La- 600C A
Phone Number:
Email Address:
I certify that I have authorized
l 8 / 4-2,1 -
1DInfrri t R 5o A'mai C om
e,i c
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: rrw-54t:�'t ( 5,(/ po�c�
at my property located at a03 �v a� f�j 57-�- w+cZ✓��
in County.
l furthermore certify; that I am authorized to grant, and do in fact grant permission to
Division of Coastal Management staff, the Local Permit Officer and their agents to enter
on the aforementioned lands in connection with evaluating information related to this
permit application.
i
Property Owner Information:
RECEIVE
Sign ture FEB 2 4 2017
�� fc( 1�lasf h ®CM- MHD CITY
Print or Tt pe Name
flow DLA/nei"
Title,
RECEIVED
Date �,—
JAN 13 2017
®CM- MH® CITY
This certification is valid through _�l l U 1 i
j

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
,!e.reb'v _Pr1ify that I own properly adjacent to i CL L,---
(Name of Property Owner)
pr.')perv,j, tocated at
(Address, Lot, BI9ck, Road. etc.)
< !n e N. ZZ
Countyj
(Waterbody) (City -YndToi -
The aGpl!'art nas de5cft'e'a tc ­';e a�r. --.?i.,,wr
! no :D.)jedio4 , lo ',hs
I :�')jeGrions t',i this
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(individual proposing development must fill in description below or attach a site drawing)
e a
xj
RECEIVED
FEB 2 4 2017
WAIVER SECTION
I understand that a pier ock- rocring ;D;Iings, boal ramp, Lreak.water :)()ijthoL;se. PM,-rqM HD CITY
rruqt be sel bacK :i minimum dimance al: 15' fron) 'rV area Y riDanar aCCeSS
t—C Jf OU wis- tc, waiip the SetbaC._:yGL must initial the a p-cnrte t)la r)K b
do msh to -.Nar,,e tnc 15' --,etback re2,wtef­,�,"
do not wvsh to 4,ajve the 16'�etbac-. rem,.r5,npni.
(Prpqorty Owner Information)
Pe'ntar 7 ype fqa-re-
Louis e Ave
al io OL, '-:A
-tv"St ate
rVN C? 50 (P C -com
'aLc fir :ale
(Adjaqjg ProjCertj Owner information)
rgl
L6 5a e", 1
2, 61�
9i-.­,,,sf71A,,,,j 2,,RECEIVED
JAN. 13 2017
DCM- MHD CITY

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to t c� •4 iy I 9 1S ::LJ yu s
r (Name of Property Owner)
property located at �D3 � S-t—
i (Address, Lot, Blg�ck, Road, etc.)
on �r < �s-" oo c in ��/ pc�lao jl�era �( 'p r ey , N.G.
(Waterbody)' (City/Tovwb dndTor County)
The applicant has described to me, as shown below, the development proposed at the above
locatio
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®
FEB 2 4 2017
®CM- MHC CITY
WAIVER SCTION
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.)
1 do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Pr rty Owner Information)
•t
Print or Type Name
C, S 3'? Low;Se rove
Marli g Add ss �„ � O
4 L R
City/State)Zrp 5D I
$s8rl 42r— ' �'
Te &vNumber / email address
,
ate
'Valid for one calendar year after signature'
wnt Property. wi
1\9(. 1 V xe,
or Type. Name%
I
►t e Y, %
��
one Numb�err e,_ it dress
---- RECEIVE®
(Revised AugJAN 41 3 2017
®CM- MH® CITY