Smith, Hubert

❑ ES ❑ PTS
❑ IH ❑ UBA ❑ N/A
❑ FC
A yes / o Crit.Hab. yes / no
. � Pier (dock) length r
Platform(s)
Finger pier(s)
Groin length
number
Bulkhead/ Riprap length
avg distance offshore
max distance offshore
Basin, channel
cubic yards
Boat ramp
Beach Bulldozingy
Other
4
A building permit may be required by:
Notes/ SRecial Conditions
City Il;:t X A,
Phone #
Adj. Wtr. Body tu
Closest Maj. Wtr. Body —
A p�o�
ZIP_
Basin
(Scale: )
River Basin

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' ite 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 consistent with the North Carolina Coastal Management Program.
River Basin Rules Applicable To Your Project:
Tar- Pamlico River Basin Buffer Rules El 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 Citv Headauarters
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

Applicant: Date:
Describe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
found in your Habitat code sheet.
TOTAL Sq. Ft.
FINAL Sq. Ft.
TOTAL Feet
FINAL Feet
(Applied for.
(Anticipated final
(Applied for.
(Anticipated final
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
disturbance.
Habitat Name
Choose One
includes any
Excludes any
total includes
Excludes any
anticipated
restoration
any anticipated
restoration and/or
restoration or
and/or temp
Wtoration or
temp impact
terup impacts)
impact amount)
-Ienip. impacts)
amount�
Dredge El Fill ❑ Both [I Other
01; Icmll"
Dredge E] Fill'E] Both E] Other 1­1
Dredge El Fill El Both El Other [I
Dredge El Fill F1 Both [I Other El
Dredge El Fill El Both [I Other El
Dredge [I Fill 171 Both 'E] Other 171
Dredge 0 'Fill 171 Both 171 Other [I
Dredge El Fill El Both f-1 Other El
Dredge [] Fill[] Both E] Other tj
Dredge El Fill 171 Both El Other F1
Dredge ❑ Fill El Both El Other El
Dredge El Fill [I Both El Other 171
Dredge Q Fill El Both [I Other El
Dredge El Fill El Both [I Other F1
Dredge El Fill [I Both [I Other [I

4
Pat McCrory
Governor
A
ALI;
NCDENR
North Carolina Denartment of Environment cand Natural Resources
Division o;I'Coastai Management
Braxton C. Davis
Director
Date g—ja— /' 3—
Applicant Name
Mailing Address
John E. Skxvarla, III
Secretary
I certify that I have authorized (agent) i�7 'EOW' ["'(fk?-J/eto t on my behalf, for the
)C1
purpose of applying for and obtaining all CA Permits necessary to install or construct (activity)
�- 'A erm
e- L-
rlfck e .+
This certification is valid
Signature
(date)
400 Commerce Ave., Morehead City, NC 28557 One
Phone: [phone] \ FAX: [phone] Internet: www.nccoastalmanagement.net NorthCarolina
An Equal Opportunity 1 Affirmative Action Employer Nate"

ADJACENT RIPARIP N PROPERTY OWNER STATEMENT
R
I he�teby certi ~Ir that I own property adjacent to II'' 's
Name f, Property Owner)
property loci ed at C 2 _
_rI Address Lo,�1 E rck oad etc:.
on toys C �� e _'in __-6 _o� v Gto`T �• � f�.C.
( Vai:erbody) (City/To)(in and/or County)
Thel applicar is described to me, as shown below, t--ie development proposed at the above
location.
I Iiave no ob ection to thi a proposal.
I liaue objections to this proposal,
IIE ;CF:'1PTIOAI AND/OR DRAWING OF PPOPOSED DEVELOPMENT
(in c>Iia(it'ilual l ro,:)o-,;ing dei,,elopment must fill in d sci;iptio below or attach a site drawing)
�_D4
0
\J s�
V �J vK
VWAIVER SECTION
I ui derstand the it a pier, dc: ck, mooring pilings, breakwater, boathouse, lift, or groin must be set
back a minirium distance of 15' from Iny area of riparian access unless waived by me. (If you
wish to waivo th a s.;tback, you must initial the appropr ate blank below.)
II d )- wish tow aive the 15' setback requirer )ent.
I d o riot wish to waive the 15' setback req.airement,
(PrOpertyt O rvn !.r I nforma":ion) (Adjacent PZrokertV_gwner Information)
or
Date
re �f Sze
nn I
�vpe i.�e rir
� Y
addr s ('� Ma,
_ .
r � 0 CifS
ne NJ tier Tell
or z ype ►vamc����
'n ddress
ho� ber
0 �
(Revised 611812012)

;ADJACENT PAPJA
I heifeby certiy teat I own property adjacent to
progerty local ;ed at
on
's.
Thelapplicant Ms described to me, as shown below, t-ie development proposed at the above
catiL-/l
have no ob.ection to thl; proposal.
I have objections to this proposal,
I11 ,CRIPTION' ANDIOR DRAWING OF PF[OPOSED DEVEL;Fh
ENT
onath► Wl i ro,:)osfng development nrrtst fill In desci � ffontbelow a a sife drawing)
�I
WAIVER SMION
I unite tand th;it a pier, dick, mooring pilings, breakwater, boathouse, lift, or gr in mul be let
back a minlr lure distance of 15' from my area of riparian access unless waived by me. (If you
wish to waiva the setback, jou must Initial the appropr ate blank below.)
d ) wish to waive the 15' setback requirerient.
t I do not wish to waive the 15' setback req ,airement.
party O rinarJ (AdjacentPro party Owner Information)
tje
e�
ow ,`' t1$fa ,�� f 7 G ✓�'s a
o Tye Vat.�p r Pt7rtMli ct 60
Mailing dress V C Z I%S"� C�
VS Stolz( Cif �d b
.2 72 t q
� 7-78—r,�
:T? 1 7—?
Dare
(Revised 61IM012)