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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:
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/ 1-888-411COAST
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

AGENT AUTHORIZATION FORM FOR PERMIT APPLICATIONS
Name of Property Owner Applying for permit: k -jULo O p "Z
Mailing address:
Telephone Number:
�irrG
YI 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 f cc
at my property located at 10q Clu
CAPS
This certification is valid through (date).
iifle, co. owner ortrus ee for property
Date
A;��-CA 9 - � 14S-)
Telephone Number
m-
mail Address
RECEIVED
APR 2 9 2015
411j�j V'.JUWi;W
5101 9 9 aan
a3AI3036
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JA ENT RIP FiIA IZO . TY O NER ST 7EME
I hereby certify that I own property adjacent to
s
property located at. V (Nprne of Property Owner)
(Address, Lot
on ; in Ai0eW
(Wateirbody)
(city/Town and/or. County)
The applicant has described to- me', as shown below, -the development proposed a.t the above
IocafiQe,
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF. PROPOSED, DEVELOPMENT
(Individual proposing developmen( must d lh.descdpUon 66/ow Ok.at(ach`a site draW1hg)
rJ� `t' tz�tiI Lt
'Eais7'i1JG
NE. Set .
I understand"lhat a pier, dock, mooring• pilings;, boat; ramp, breakwater; ,boathouse, Ilff, or groin
must be back a mininiurn distance of 15' from my'area of"ripartan access.unless walved.by
me. (If ou wish to waive the setback, you must Initial il,e appropriate blank below,)
o wish to waive the 15'.setback requirement;
I do not wish to waive the 15' setback requirement.
(Property Owner lnformatlon) \ (Adjacent•Pioperty OwtierTnro tlon)
IF
Signature
' •,SCFxT
P r pi 'r, a Name PriR or type Nome
PA fit Address MBilirig'Add/oss
' C�111t14�1LC_ �0 5f C-XA<_ G7d 0e Tc 2E r E1V ED
Cily/8toWD Citymatwip RFC
L1^
Telephone Number/er»eil address Telephrure Number/emel/address
�rI 2LJ.�V,�i ,�.., 9/9 �d v.'a�9�•. �At�K �!}a,4
"Valid for one•calendar year after signature'
(Revised Aug, 2014)
RECEIVED
APR 2 9 1015
9.I?Y
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ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to ^ 0J '" S
property located at v (Name of Property Owner)
(Address, Lot lock, oad, tc.)
on in 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
(Irjdivrdpal.APP.o./ii8` devela.. P rrienirnt0-St.. r%`ln:d .scii ;P'tion:til;low or: tfa ti''a its dPawing)
R�nF
i sV tzzzd
D4 pT�irol�M
NE"J
ai0-rL J� RECEIVED
s S O-c APR 2 2 2015
NEW 6)(1
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.)
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
.(Property Owner Information) (Adjacent Property Owner Information)
Sf n tore
L/ i.0,04
Print or Type Name
27s7 ' Orcw;� 16 p
M fling Address
City/State2ip
M- Zg F- )J -!cr
Telephone Number/email address
.462t Zo 2wr
`Valid for one calendar year after signature'
Signature
Prinf or Type ame
Meilin Ad
ao
Cj%ya fe2p� c j �p • iJ~C� L� RECEIVED
Telephone Number/email address APR 2 y 'ra`'`
Date* PClt^.!�D CiTv
(Revised Aug, 2014)
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