Quesenberry, Robert G.

R/
CAMA / DREDGE & FILL
GENERAL PERMIT
rINew ModificationComplete Reissue Partial Reissue
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 15A NCAC
Applicant Name
Address
City _ - --_ --- __- State- ZIP
Phone # (- -- )-- --- = -- -- Fax # (-._ )
Authorized Agent
Affected CW ; EW PTA -] ES PTS
AEC(s): OEA 1-1 HHF IH ❑ UBA I N/A
PWS: F7 FC:
ORW: yes / no PNA yes / no Crit.Hab. yes / no
IType of Project/ Activity
Pier (dock) length
Platform(s)
Finger pier(s)
Groin length
number
Bulkhead/ Riprap length
avg distance offshore
max distance offshore
Basin, channel
cubic yards
Boat ramp
Boathouse/ Boatlift
Beach Bulldozing -
Other
Shoreline Length i
SAV: not sure yes no
Sandbags: not sure yes no
Moratorium: n/a yes no
Photos: yes no
Waiver Attached: yes
A building permit may be requirec
Notes/ Special Conditions _
Agent or Applicant Printed Name
Previous permit #
Date previous permit issued
Rules attached.
Project Location: County -
Street Address/ State Road/ Lot #(s)
Subdivision
City ZIP
Phone # ( ) _ - - River Basin
Adj. Wtr. Body - - _ (nat /man /unkn)
Closest Maj. Wtr. Body - - - - - --
(Scale: ( ll.: 5 )
Permit Officer's Signature
Signature "Please read compliance statement on back of permit"
Application Fee(s) Check #
Issuing Date Expiration Date
Local Planning jurisdiction Rover File 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, certify thatthis project is consistentwith 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 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 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

GP Habitat Sheet
Name: Robert Gregory Quenseberry R.L. Trust Permit #: 64171C
Date: 8/21/14 Address:105 Broad St
Habitat
SF of Disturbance
SF of Disturbance
LF of Disturbance
LF of Disturbance
Open water
169
169
N/A
N/A
b =:�, RECEIVED
AUG 2 2 2014
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N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date�/q L,�-o�
Name of Property Owner Applying for Permit: RO L i l G7 0,f�ti�t
Rewot
Mailing Address:
PO 906 6%
b i a hVA
I certify that I have authorized (agent) T_l vvL (;n'iv\e_5 to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or'construct (activity) g bc\ f t l "+
( yproperty ) 6�� J G +� 61 at mlocated at 1''6 ct r�� IL E "� NC c�-&lj
This certification is valid thru (date)
RECEIVER
AUG 12 2014
AUG 2 2 2014
pcM-ymcrry
DCM-MffD CMy

ADJACENT RIPARIAN PROPERTYOWNERSTATEMENT
1 hereby certify that 1 own property adjacent to &Vzb 's
(Na a of rty Owner)
property located at I
�a (Address,
on l in
(Waterbodl
RECEM'D
(Cityrrown and/or County)
The applicant has escrlbed to me, as snown oeww, UIC UUVGIUP111011L FZ%Jtj ,.-- +• •••� ---___
Ioc 47' AUG 0 7 2014
�� ave no objection to this proposal.
I have objections to this proposal. _ 1�CM-I�FiA CIS
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(individual proposing development must till in descr/ptlon below or attach a site drawing)
b
0
:2
T
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or.groin must be set 16
back a minimum distance of 16 from my area of riparian access unless waived. If you
wish to waive the setback, you must initial the appropriate blank below.)'. .
�i
I do wish to waive the 15' setback requirement: AUG 2 2 2014
1 d not wish to waive the 15' setback requirement 1
/ . p t1f' PA"T"rrry — -9
(Property Owner Information) (Adjacent Property Owner Information)
Sign `
.Signature
Print or Type Name Print or Type Name W aw %Llet&aq�
Mailing Address Mailing Address /�
City/Stateop Cdy/StatelLip � c /, / � -
Telephone Number
j1
Telephone Number a S.A ZR 2 C�
Dale Date
/711 (Revised 6✓18/2012)
5 77�
00,

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
's
I hereby certify that I own property adjacent to
�' (Na a of Pro rty Owner)
E �-
property located at
(Address, Lo ,block, R d, etc.)
'-- ''t N.C.
(Waterbody) (Citytrown 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 till In description below or attach a site drawing)
/ AUG 1204
D
�: 3 Mxncrr�'
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
wish to waive the setback, you must Initial the appropriate blank below.)
LWA
I do wish to waive the 15' setback requirement.
I do not wish to waive the IS setback requirement.
(Property Owner Information) (Adjaceen
Print or Type Name
Mailing Address
Citylstatemp -
Telephone Number
Date -
Telephone Number
Date
AUG 2 2 2014
(Revised 611812012)
DCM•MHD CITY