Rave, Joy Simpson

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Nil'! 67864 'C D A B
ENERAL PERMIT Previous permit #
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As authorized by the State of North Carolina, Department of Environment and Natural Resources
and the Coastal Resources Commission in an area of environmental nvironmentall concern pursuant to I SA NCAC
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A building permit may be required by:
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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:
0 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 complywith these buffer rules.
Division of Coastal Management Offices
Morehead City Headquarters
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

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N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date OCT 14 . U I (o
Name of Property Owner Applying for Permit:
,. o`/ StmPso(j RME
Mailing Address:
l 5 3 ?oL (::�T
I certify that I have authorized (agent) j+v �� d�wcie� �. •.����� to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity)
at (my property located at) q F4Rr)M1 sT
This certification is valid thru (date)
® ®emvL—w v LsL/
OCT 2 0 2016 RECEIVED
DCM- MHD CITY OCT 17-2016
DCM- MHD CITY

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Project Name IEZ Dock Solutions
Project Name
PRVA4ED FOR 5568 Hwy. 70W,
Customer Newport, NC
arc MOM mLL mm w. 252-764-1234
Dra
Drawin Number PHONE NO
Drawn BI Date 252-648-8026

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to'1oy Gi mpsnKI RAVC 's
(Name of Property Owner)
property located at 1.55 a FpD/�T a
i (Address, Lot, Block, Ro ,, etc.)
on � /LQC�S CREEK , in8_IFLN I , 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)
RECEIVED
OCT 17 2016
DCM- MHD 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
�Tj)
wish to waive the setback, you must initial the appropriate blank below.)
I do wish to waive the 15' setback requirement. RECEIVED
I do not wish to waive the 15' setback requirement. OCT 2 0 2016
(Prope wner Informatio
Sign ur
vE
Print r Ty a Name
S a FRONT sT
1 ilinPST j i' I ES I L
City/Statexz
asa nd�� 3lo�t I�u, raven�ou� .�onn
Te/ ho a Number/ema' ss
O
Date
*Valid for one calendar year after signature*
(A 'a Prope o ation)
- MHD CITY
Si ature *
HARKS PRE EZE
Print or Type Name
f 534 FRoNIT S T
ying Address
EAuf-:-0(Rr. NC aglgt►'
City/State)Zip
3.3L • 80q • s& 14
Telephone Number/email address
Date*
(Revised Aug. 2014)

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
r
I hereby certify that I own property adjacent to �dy I NA'Pspu C "t y 's
IE5ZaF � (Name of Property Owner)
property located at
(Address, Iot, Block Road etc.)
in [:7��1��D I�T , N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
loca ' n.
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
m'
(individual proposing development must fill description below or attach a site drawing)
'Se-e- C-;I-U - ep, l HT
RECEIVED
OC T 17 2016
ACM- MHD CITY
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or groin
must be -se back a minimum distance of 15' from my area of riparian access unless waived by
me. o ish to waive the setback, you must initial the appropriate blank below.)
I do wish to waive the 15' setback requirement. RECEIVED
I do not wish to waive the 15' setback requirement. 0 C T 2 0 2016
roperty ner Information) (Adjacent Property 49N`Wlafh40W181TY
1:
Si tur SiWture
;>
Print or Type Name Print or TypeName
l 5!:�a F Can UT ST /4Q,0 AA4a- .
J1 Addres Mailing Address
QRM
it /Sta /Zip A City/Stat ip
g
Owl .r "'I ADIM 0?Jgg- ?6q4 ser6dfnJ(9ee•rr. Cor»
Telephone Numberlemak a ' s Telephone Number/email address
�©(t9ad�c� /o - 14- ao16
Date ��, Date *
(Revised Aug. 2014)
*Valid for one calendar year after signature*