Polgardi, Alex

N
i •CJCAMA / J DREDGE & FILL NO 72090 A B C D
r. GENERAL PERMIT Previous permit#
-New Modification El Complete Reissue El Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality .'� ­7 f / .—, .. ,
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC DRules attached.
Applicant Name I Project Location: County
Address +� ", �' Street Address/ State Road/ Lot #(s) t
City_..{ i ' Stated ZIP}
Phone # ( )___ E-Mail f Subdivision
-Acnthorize d'Agezt
ElCW ❑ EW © PTA El ES C PTS
Affected AEC(s): ❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS:
ORW: ves / no PNA yes / no
City
ZIP
Phone # O River` Basin
Adj. Wtr. Body' } °�i�' t • (nat /man /unkn
Closest Maj. Wtr. Body
lwr
Agent or Applicant- ame
Signature Please read compliance statement on back of permit **
Permit Officer's Printed Name
s
Si at
1 k
Application Fee(s) Check# Issuing Date
iratiBn 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, 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 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/ 1-888ARCOAST
Fax: [phone]
(Serves: Carteret, Craven, Onslow -
North of New River Inlet- and Pamlico
Counties)
Elizabeth City District
401 S. Griffin St.
Ste. 300
Elizabeth City, NC 27909
252-264-3901
Fax:[phone]
(Serves: Camden, Chowan, Currituck,
Dare, Gates, Pasquotank and Perquimans
Counties)
http://portal.ncdenr.org/web/cm/dcm-home
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)
Revised 7/06/17

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to
ert located at 1 61) /
e of Property Owner)
prop y Block, Road etc.)
(Address, Lot, � /1 �/.N /� , N.C.
one✓�(Z���n/,�� in &L Y*t`(1
Waterbod (City/Town and/or County)
(n �►� TA�Ni V t �/!�
ThL-a licant has described to me, as shown below, the development proposed at the above
pp
loca '
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)
iD�, &,'-< 6r �0cL
RECEIVED
FEB 12 2018
DCM- MHD CITY
WAIVER SECTION
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.
(Pro e, y Owner Infor ation) 1~"Xf�"`r'"P"
Sig r p Signature*
u
_ K_K f - A f-/ 11)
t e Name
Prit7or Typt� Print or Type Name
/0/ K✓L o i�-,/vf fZ Q
Mair,A esse5�N ,� `G
City/`/S�late/Zip / / �0"3C�
Telepho e N C�mber/e Imoail/address
Date
`Valid for one calendar year after signature"
Mailing Addrej�s }
City/Sta(,e2ip
�a n C-
Telephone Number / email address
Date* r j
(Revised Aug. 2014)

AGENT AUTHORIZATION FORM FOR PERMIT APPLICATIONS
Name of Property owner Applying for Permit:
Mailing address:
vi AL-PW AIC,
Telephone Number:
ift"Mi'll -oa
I certify that I have authorized (agenticontractor),
to act on my behalf, for the purpose of applying and obtaining all CAMA permits
b 0 C V- (z
necessary for the proposed development of
0
at my property located at /0/ 1
certification is valid through
AbjP( 4—NLI:EX-�K
j5n�nt or Type Name
P0L&pe ) 7,7
Co. owner or trustee for property
63d3
Te'lephone Number
'- -.4 A K I- n1-.
Tao A 0
Email Address

kcAMA /❑ DREDGE & FILL N272090 A B C D
GENERAL PERMIT Previous permit #
ONew ❑Modification ❑Complete Reissue El Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC ❑ Rules attached.
Applicant Name ;
¢ i i Project Location: County
Address Ifs
Street Address/ State Road/ Lot #(s)
` r State t ZI� ��
City , y
Subdivision
Phone #
ZIP
Authorized, AI
❑CW ❑EW " _-PTA ❑ES ,PTS Phone # ( )
River Basin
Affected ❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A - nat. roan' /unkn
AEC(s): Adj. Wtr. Body ¢
Closest Maj. Wtr. Body
ORW: yes / no PNA yes / no
Type of Project/ Activity, k,%'�
Pier (dock) length
Fixed Platform(s)
Floating Platforms) bo Oc
Fingerpier(s)
Groin length
number
Bulkhead/ Riprap length
avg distance offshore I
max distance offshore
Basin, channel
cubic yards ,_--
Boat ramp ..
Boathouse/ Boatlift Ir'
,r
Beach B,ul zin
Shoreline Length ,
SAV: not sure yes,, t no
Moratorium: n/a yef no
Photos: yes no 7
Waiver Attached: yes no ,
A building permit may be required by:
Note Local Planning Jurisdiction)
Notes/ Special Conditions _ 1 '� j
NAM
Agent of Appll varnG
Signature Pleaseread comp llance statem onback ofpermite*
Check #
(Scale: )
❑ See note on back regarding River Basin rules.

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to 1JA,,JJ. A-L-, � Po 1644'J\ 's
l /� (Name of Property Owner)
property located at / Q/ �� !e T fv� P I
(Address, Lot, Block, Road, etc.)
on c ✓4'y/iL in 1 ✓'�`a ✓.I , N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
loccitloo.
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)
Xll1 �ai\;
0J �--(3
�ock
RECEIVED
FEB 12 2018
WAIVER SECTION
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.
(Prop,prty Owner Infor ation ( dja nt Prop O er Information)
/� ,
J
Sign fore Si nut re * —�
Print or Type Name Pri4 or Type Name
Mailing Addr ss Mailing Addres
kf'`" ��`QN, IV( 6a IR:� �CAJ RIG
te/Zi City/St p City/State/Zip
92� - 6 �s- ( 3 � 3 asa- 638�--39410
Telephone Number/email address Telephone Number/email address
Date IDate
(Revised Aug. 2014)
`Valid for one calendar year after signature"