Pate, Tim

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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, certifythatthis project is consistentwith the North Carolina Coastal Management Program.
River Basin Rules Applicable To Your Project:
Tar - Pamlico River Basin Buffer Rules
EM 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 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 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:[phone]
Morehead City 146adquarters.
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

AG E:N'T ) WTHO.RIZATION FORM FOR PERMIT APPLICATION"'
Name of ProportS, O +vner Applying for Permit:
Mailing addres>: 1 4-A L_ cX_p,.,,�� K L A
Telephone Nur ter: z 5 z. 3 e. i. 13 9z,
I certify that 1 h �IvE: ai ithorize d A_(�
a en cc rtractor
to act on my bE half, i ar the r: urpose of <:pplying and obtaining all CAkMA permi >
necessary for the pitpos(i,.d developmel it of P I � �
at my property I oc ate I at- a 7,. ©-�--
This certificatioi i is valid through _ (date).
(Property Own :!r ! nformvtic-n)
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APR 15 1015
Print or 7 �,po N gme
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Title, co; owner - �,,r rru: tee ; or property
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Telephon-:. Number
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,AE; IAQf-N';E; RIPARIAN.'ROPERTy QW1 JER STATENU T_
I herdby certif r that I )wn property adjace I to �I �°' _
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prop41ocat.: d ;�t _. •• -
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(YI I'ab I rbotf y) (I;, itylTown andlor Cosa nty.
The Applicani ha ;: d : seff le:dl to me, as s i sown below, the ,Development i.xoposed al -ie above
location
I haw no o aje� cation to this i; ropo AcH ..I ��+� boside u v4 Pie F; {; y� eati
I h,ivf+ obje u-tip;ris to this pr+:posal. �J
S':R 'TJQW!�,ND/OR MMING OF PROPOSED DEVELOPMENT
(ln+diVidual �uPosi tg d aVe.�l. f mt,;>t rill in descrip�ion'below or,fittacii ash drawinyj
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I ui iderstand hal a tier, iioc (, mooring f, lini
mu t be set t :rich: a ninirriur, distance of 15'
mel Of you *i h ' 1) V give he setback, yot mi
do wi! h to 1,vai ire the 15' se
boat ram f breakwater, boathouse, t, or gr
,m my are:: of riparian auxm unless Naived
initial the appropriate bls::nk below.)
idc nc t wish tc: waive the 1 setback requiru mnt. -
(Pr6oeerty Ov ne r In `orm.atic n)
(Adjac. nt Property Owner Info
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(Revise, 4ug.2014)
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