Roberson, Marcellus

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GENERAL PERMIT CC, L L Wxevious permit #
PNew DModification ElComplete Reissue ElPartial Reissue ,.,O[?ate previous permit issued
9 C,
As authorized by the State of North Carolina, Department of Environment and Natural Resources
and the Coastal Resources Commission in an area of environrental concern pursuant to I SA NCAC ©Ryles attached.
C C"� r
Applicant Name Project Location: County
(--11// L/
Address Street Address/ State Road/ Lot #(s)
City—, State AX ZIP 5
Phone # (Vh /I 'E-Mail Subdivis 1op Authorized Agent City XI. ZIP A,P)
Affected El CW DEW -! . CrOTA El ES 0 PTS
AEC(s): D OEA El HHF 0 lH 0 UBA ON/A
E] PWS-
/- i -- ORW: I ye no IPNA yes f-no
Type of Project/ Activity V ff
Pier
Fix
'Zat
Fing
GroitBulkh
Basir
Boat
Boat
Beac;
Oth
Sho
SA
Mo
Pho
W.
Phone# ( f Ir River Basin
Adj. Wtr. Body 0 Cat /man /unkn)
J
Closest Maj. Wtr. Body ,
Vf3 I
(Scale: '1r-
ng Platform(s)
r pier(s) V
length
number
ead/ Fjprap length
avg distance offshore—_
ENE
MEN
i
NNE
ii
momENNEENE
MENNE■
,channel
MIN
IN
IIIII
EIIIIIIIIIIIIIIINEIIII
cubic yards
ramp
MENEM
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oil
MMON
ENE
Bulldozing
MAKIN
MEN
=NEON
mffi"MIMNMNE�ommoom
5
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0
EMENEEME
not sure yes
,
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MENNEN
rium: n/a yes
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Attached: yes
ME
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A building permit may be required, by: See note o back regarding River Basin rules.
Note Local Planning jurisdiction)'
r
Notes/ Special Conditions
Agent or Applipnt Printed Name
Signature-) "Please read compliance statement on backpf pe rmit**,
4
Application Fee(s) L CheckW 11
PermitOfficet:s erinted Name
N
Signature f I
Issuing' Date Expiratioh Date

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 ❑ 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 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 comply with these buffer rules.
Division of Coastal Management Offices
Morehead City Headquarters
400 Commerce Ave
Morehead City, NC 28557
252-808-2808/ 1-8884RCOAST
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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AGENT AUTHORIZATION FORM FOR PERMIT APPLICATIONS
Name of Property YOwner Applying for Permit:46vu,"��°' �IYL
Mailing address: '1'"l��f AFmwr 0&-
C9-lSf
Telephone Number:
/Z 1 certify that I have authorize . � (agent/contractor),
to act on my behalf, for the purpose of applying and obtaining all CAMA permits
necessary for the proposed development of '
at my property located at
This certification is valid through C 2C I w ^ -Z ® 1,_�g (date).
(Property. Ow or Information)
Si nature
Print or Type Name
RECEIVED
Title, co. owner or trustee for property SEP 01015
Date
9/s) 5�r .Iro
Telephone Number RECEIVED
SEP 0 8 2015
Email Address

ADJACENT RIPARIAN PROPEERnTY OWNER STATEMENT
I hereby certify that 1 own property adjacent to _�' !/lt�i'l�l,� i -VIV , t
/ /Z 's.
Property located at / 1,;IV,� Lr J (Name_ f Property Own(r)
on (address, Block, Road etc.)
( /inn„✓� in ;=r' t� 1a`u� (�3ftr�z�.-r-
(Waterbody) , N.C.
(City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location••
? ' _ 1 have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING
(IRa'ividual proposi
_ OF PROPOSED DEVELOPMENT
... .
ng deveio irientmustfi/ln.descrfption belowor.attach'a site draryin91
P'
�fi
2.
LJ
J WAIVER SECTI_T
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, I ft 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.)
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
.(Property caner Information)
grtature
Print or Tvpe Name
Address
try/State/Zip
Telephone N ber/email arlrim Jo
Date
(A4,,,ant Property Owner formation)
Sie
Print nr Tim.
,a Y--coxaU
hone Number/email address
c—
Date*
'Valid for one calendar year after signature* (Revised Aug. 2014)
RECEIVED
SEP 10 20b
�-55-VIC.
-a,E NG
RECEIVED
DEP 0 8 206

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to
1� '"1 'fi ----R ,y �JI2 '
Property located at �)` 1U.t/:, L (Name of Pro�atj
rty Owner)
on 7 (Address, � to
jts ;r B ck, Road,.
(Vtlaterbody) in N.C.
(City/Town and/or County) '
The applicant has described to me, as shown below, the development proposed at the
location above
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing deve/opmentmusf A t n_ description below or. aftach:`a zs1te ofra wmgl
Pal
46 fix IgI'l e3�
I understand that a pier, dock moo i WAIVER SECTION
must be set back a minimum distance of 15' fromomy area of riparian access unless r, boathouse5k or groin
me. (If you wish to waive the setback, you must initial the appropriate blank below.) waived by
— I do wish to waive the 15' setback requirement
I do not wish to waive the 15' setback requirement.
.(Property wrier Information)
�j Aent PropertyOwner Information)
atureore
Print or Type Name L/,tJ W crc
_�/ —,, R n Print orTvoa ivq--
M gAddrs-ss
(.ity/State/Lp
Telephone N ber/email address
Date
'Valid for one calendar year after signature!
RECEIVED
SEP 10.10
� .R'f
RECEIVED
Mat ' Address �Y- v Sip 0 8
L L1�L �g
/SBb
tate/Zip
Telephone Number/email address
Date #
(Revised Aug. 2014)