Shigley, Hal (2)

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I
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, certifythat this project is consistent with the North Carolina Coastal Management Program.
River Basin Rules Applicable To Your Project:
Tar- Pamlico River Basin Buffer Rules HN 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 how to 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/ 1-888ARCOAST
Fax: [phone]
(Serves: Carteret, Craven, Onslow -above
New River Inlet- and Pamlico Counties)
Elizabeth CityDistrict
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

Applicant: G/' ' `�
Date:
Describe below the HABITAT distur ances for the application. All values should match the name, and units of measurement
found in your Habitat code sheet.
Habitat Name
I
DISTURB TYPE
Choose One
TOTAL Sq. Ft.
(Apply d for.
Disturbahcetotal
includes any
anticipated
restoration or
temp impacts)
FINAL Sq. Ft.
(Anticipated final
disturbance.
Excludes any
restoration
and/or temp
impact amount)
TOTAL Feet
(Applied for.
Disturbance
total includes
any anticipated
restoration or
temp impacts)
FINAL Feet
(Anticipated final
disturbance.
Excludes any
restoration and/or
temp impact
amount)
�El Other El Dredge [I Fill, Both
Dredge El Fill [I Both El Other D
Dredge [:1 Fill [I Both El Other [:1
Dredge [I Fill El Both El Other El
Dredge El Fill El Both El Other El
Dredge El Fill 171 Both'E] Other El
Dredge 0 Fill El Both [:1 Other El
Dredge El Fill [I Both 171 Other ❑
Dredge D Fill El Both El Other 171
Dredge El Fill El Both [I Other El
Dredge C1 Fill [I Both El Other 0
Dredge El Fill El Both [I Other El
Dredge El Fill [I Both [I Other El
Dredge [I Fill El Both El Other 171
Dredge El Fill [I Both n Other [I

i lcx -h %Groi?i 1C
Rat Wcrory
Governor
Date _ % 4113 __...N
DEN
artmec t of Erivironrr er t and 1 'iatu ResOU
DlVisior) )f COastQl Mar,ag(!:'np"t
E raxion, C. Davis
nirector
Applicant Name
Mailing Address
LILL,01
Jain
Secretary
I certify that I have a ithorb, ed (age iit) g—e-h— — to act on my behalf, for the
purpose of applying i 6r ind obtaini.lg all CAM, k Permits neces<. ;try to install or construct (activity)
Au 1tk eg -- , at (location;
This certifi<catio i ven lid thru (date)
Signature Akw4L.
400 Corhmerce Ave. Ift: hey I City, NC ?8557 One
Phone: �52-808-280, -1 R X: 232-247-33" ) Internet: www.r xoastalmanagement.nd NorthQuolina
An Equal Opportunity 1 Affii Pah Antic i Employer )WAIriallff

1
(YYa at odd)
or County,
'The applicant has described to me, as S1,10virt below, tTle deve;opi-rent propos8d at the clbove,,
location.
I 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 bel w r attach a site drawing)
•v
t3�
V7::7 WAIVER SECTION 1::14
1 understand that a pier, dock, mooring pilings, breakwater, boathou e, 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 tow aiv 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.
Telephone Number
Date
(Ad" ac cProper Owner Information)
S' nature ,
1C-R,-
2�Print or Type Name
104�
M iling Address
CityIStatelZip
9/0 5-6,4-3g09
Telep one IVumber
Date
(Revised 611812012)

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rl
44� I ,A
( Vaierbody) I.CYlTown 271dior cr_,urr! j)
1i'1-' ^;Jii�)r�lfl{'fcl:' i::: �tr'3fJ3C1 f�1 Y't1 `, t :i`1O'v1JYi i1 d.,/�ejopi' ere proplJ'sed at Y(ie i:`J���I'c;
locate .
— I have no obje-,tion. to this �ropcsal.
_— I have objectic ns to this prDposal.
DESCRIPTION JkND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individ{ral proposir-g deve lopment me Ist fill in description below cr attach a site drawing)
i
YCr
i
` Wi11VER SECTIO('
I understandthat a p:er, doc:c, mooring rilings, breakwat !r, boathouse. lift, or groin must be set
back a minimum distance of 15' from m,t area of ripariai i access unless waived by me. (If you
wish to waiv tl a set)ack, y( u must initial the appropria e blank below.)
I dow:s •i to wane the 15' s(!tback requirement.
I do no-i wish to waive the 15' setback requi ement.
(Prion) (Adja cent Pro ertj Owner Information)
Si 1 re Sigm `ure 7- �IJ
5yn>rLfft L-t- &o F (Act 72TE;2E
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Print or e ne Print i ;r Try,/pe Name
M ' ' Adores M A ress
Date
.. -
►ty/, I -at /Zip
C90
TeIeDrione umber
%'" L%�
Date
(Revised 611812012)

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