Andreeff, Alex

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❑CAMA / ❑ DREDGE & FILL
GENERAL PERMIT
❑New 'Modification El Complete Reissue ❑Partial Reissue
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 I SA NCAC
Applicant Name
Address
City State ZIP
Phone # ( ) ___; E-Mail
Authorized Agent
❑ Cw ❑ EW ❑ PTA
Affected
❑ OEA ❑ HHF ❑ IH
AEC(s):
❑ PWS:
ORW:
yes / no PNA yes / no
❑ ES ❑ PTS
❑ UBA ❑ N/A
Agent or Applicant Printed Name
Signa re PI read compliance statement on back of permit
Application Fee(s) Check #
No71383 A
Previous permit #
Date previous permit issued
Rules attached.
Project Location: County
Street Address/ State Road/ Lot #(s)
B C D
Subdivision
City ZIP
Phone # ( ) River Basin
Adj. Wtr. Body (nat /man /unkn)
Closest Maj. Wtr. Body
- ..
Permit Officer's Printed Name .•
Signature
Issuing Date Expiration 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 Washington District
400 Commerce Ave 943 Washington Square Mall
Morehead City, NC 28557 Washington, NC 27889
252-808-2808/ 1-888ARCOAST 252-946-6481
Fax: [phone] 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)
(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)
http://portal.ncdenr.org/web/cm/dcm-home
Revised 7/06/ 17

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: .��x ."q"\M ee � r
Mailing Address: %3 3 S-K,�o/�ffc�4U L✓✓
Phone Number: 70j —fib — 3 ! 7.3
Email Address: r�� 4�r� %< 3 7 �'iG />'�cL,` t' •6dm
I certify that I have authorized _SCz
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:�c—
at my property located at d r r- HA2, lno- Ati kC �l� � n1 C=,
in P 46o /i 1-6 County.
I furthermore certify that I am authorized to grant, and do in fact grant permission to
Division of Coastal Management staff, the Local Permit Officer and their agents to enter
on the aforementioned lands in connection with evaluating information related to this
permit application.
Property Owner Information:
Signature
Print or Type Name
Title
0.- / ,2011,
Date
This certification is valid through I I

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to _'Lxx✓y�,en/,,`tt �F 's
(Name of Property Owner)
property located at OFF IMC Indo1! AID
(Lot, Block, Road, etc.)
on V ,AlbE 1t�kF �� �/� , in / vow /cc ,* , N.C.
(Waterbody) (Town and/or Coan
Applicant's phone #: 7c3 V03- .?/7 3 Mailing Address: 133S%' A&-cu) a z,.r/
,SGc01/11r�t AGcUL ilct ='z�
He has described to me, as shown below, the development he is proposing at that location, and, I
have no objections to his proposal.
-----------------------------------------------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by property owner proposing development)
4W
I o_
(Information for Property Owner Applying
for Permit)
133 5 tf ARQvu) HcAj) L-Al
Mailing Address
�St M�rbucK , Ua aa��
City/State/Zip
7,03 -V03 - 3 /-7
Telephone Number
Signat re Date
(Riparian Property Owner Information)
1
Signature
Print or Type Name
qb
Telephone Number
Date

ADJAC'ENT RIPARIAN pROPERT
Y OWNER STATEMENT
I hereby certify that I own property adjacent to I. y
(Name of Pro er 's
Property located at cry p h' Owner)
(Lot, Block, Road, etc.)
on AA1A A EWELS E/1
ody) ' in
(Waterb
(Town and/or CountL G� ' N.C.
Applicant's phone #: 7e3 c��� _
/73 Mailing Address: i� 3$� fleet a/fff av ��
CSL.'.OlijJ/a�C .DLt.CiG �:
He has described to me, as shown below, the
have no objections to his proposal. development he is proposing at that location, and, I
---
--------------- AND/OR -------
DESCRIPTION ---------------------------------------- --- - _
DEWING OF P - - ------------------
(To be filled in b r PROPOSED DEVELOPMENT:
y p operty owner proposing development)
V�rv���CGt<-
(Information for Property Owner Applying
for Permit)
!33 ,y 4R,4cLj- ifFgj I -A/
Mailing Address
�.mrr�'.bucK UI
City/State/Zip
`703 -5/1)3 - .3 1-7 3
Telephone Number
^ �� �r
i Signat re Date
(Riparian Property Owner Information)
Print or Type Name
Telephone Number
Date
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