Stanley, John

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, certifythatthis project is consistentwith the North Carolina Coastal Management Program.
River Basin Rules Applicable To Your Project:
EN Tar - Pamlico River Basin Buffer Rules Other:
El 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 complywith 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 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

C
Applicant: �Q�I 1 T 1 �VV��✓! 1�./
Date:
4 1 � V-)
- i�:)
Describe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
found in your Habitat code sheet.
Habitat Name
DISTURB TYPE
Choose One
TOTAL Sq. Ft.
(Applied for.
Disturbance•total
includes any
anticipated .
restoration or
temp impacts)
FINAL Sq. Ft.
(Anticipated final
disturbance.
Excludes any
restoration
and/or temp
iropact amqunjo
TOTAL Feet
(Applied for.
Disturbance
total includes
any anticipated
restoration or
terhp impacts)
FINAL Feet
(Anticipated final
disturbance.
Excludes any
restoration and/or
temp impact
amount
Dredge ❑ Fill ❑ Both ❑ Other
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑. Fill ❑ Both ' ❑ Other ❑
Dredge ❑ 'Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑.
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
072-M-2001e:51, . 1-'% •-1W'G§1-23

N.O. DIVISION Or COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date `3 • '� o ' 1
Name of Property Owner Applying for Permit:
O
Mailing Address:
'::�a S w�*-a I .o •. o Or i v6
Ge-e,,N- �- -q t.4 . e_. `Zrl `pow
APR 0 8 W3
DGN-WMCffY
I certify that I have authorized (agent) m v o ��"�' i}'' '--VG to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity) jJo c. Y� ,
at (my proper ocated at) R4:
This certification is valid thru (date)
Property Owner Signature
n
Date

10
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
e -
I hereby certify that I own property adjacent to .S o 1% vJ's
(Name of Prope Owner)
property located at � 0 1 I E v vA �-� 4} -c �� �
(Address, Lot, Block, Road, etc.)
on �� � 5��• iP , in M ©9-wja e_✓j 6 o- , N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location.
:� 9�- I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR D
(Individual proposing development n
A
O
1
RAWING OF PROPOSED DEVELOPMENT
Pust fill in description below or attach a site drawing)
a
't)"c_Y�' ) 2 0
I L�--IoL���
I Lti-
d
understand that a pier, dock, mooring pilings, 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.)
'3 2- I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
I
Si ature
IS y 11 'r 4aL_
Print or Type Name
'-6 US L-- .
M ling Address
___So-L,....._
City/State/Zip
4 ct A ©o u`�
Telephone Number
Date
(Adjacent Property Own Information)
Si ature
Print or Type Name
Name
L2 V
10 1^1g11-L 11E F4D CD
Mailing Address
Grp. -5J710-X N c Z'pes�
C'g�''S (� telZio
��q
Telephone Number
/3 gW ' 3
Date
(Revised 6/1&2012)

4' IV
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to 7y �1 X.; ­51".0 VJ 's
�jHame of Property O ner)
property located at 3 o t) L/ a w 5 R.G � 1
(Address, Lot, Block, Road, etc.)
on S0,-40 —,in M orr hw-a-o G� , N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location.
W P 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)
r o
_I
A
rooms ,
IL;f�
Y.
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IMCUVED
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APR 0 S 2013
DCUMMcrly
understand that a pier, dock, mooring pilings, 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.)
wp I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
Signature
-3 o h
Print or Type Name
`d oS w 00 d t -'As
Mailing Address
(1-7szftw ba20 ry o�, 27g oc
City/State/Zip
13t, -lby- o0(.S
Telephone Number
Date
(Adjacent Property Owner Information)
Signature
Print or Type Name
60) Y'e1)-.OaD 1T)oce-
Mailing Address
C= o l J-s b o a e p •c . 2'�53.
City/State/Zip
­1 1 CPI '13 i '3r-) 19
Telephone Number
`3-SO-13
Date
(Revised 611812012)