Parker, Janess

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AMA / ❑ DREDGE & FILL
wNERAL PERMIT
❑Modification ❑Complete Reissue
As authorized by the State of North Carolina, Department of En
and the Coastal Resources Commission in an area of. environmei
%.
Applicant Narpe l � �, LlL
Phone # ('), >{-' I —�AMail"
t
Authorized Agent
Affected ❑CW 4w TA ❑ES ❑PTS
AEC(s): Ll OEA ❑ HHF I ❑ UBA ❑ WA
-1 PWS:
ORW: yes / no PNA yes / no
75086
A B C D
Previous permit #
❑Partial Reissue Date previous permit issued
ironmen[al'Qiiality -
:al concern pursuant to 15A NCAC
❑Rules attached.
Project Location: County
tregt Address/ State Road/ Lot #(s)
77
Subdivision_
City If C }�� ( ZIP
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Phone # ( }/ / ' Ry er Basin
Adj. Wtr. Body _ r (nat /man /unkn
Closest Maj. Wtr. Body
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Agent or Applicant Printed Name
Signature ** Please�readcompliance statement on back of permit`*
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Application Fee(s) Check#
PermitOffcer's Printed Name .% r--
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Signature,
Issui g Date Expiration Date

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: Ja c���S \ �C.0 )�.e.r
Mailing Address:
Phone Number:
Email Address:
aS�-�.�g-boat
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certify that I have authorized l a � \1aC k e— ; ,
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
at my property located at
in oj- e ce�y County.
r'� `J C
1 furthermore certify that l 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:
1TP �(a Il o
Signature
�C,_c-.ESS
Print or Type Name
Title
/alb/� C\_
Date
This certification is valid through
x r/
,955-a-C-9eT.-00a(
RECEtvED
JUL 'z 6 2(119
DCM.MHD CITY

Hurricane Florence and TS Michael
Replacement/Repair Request Form
Date of Request: '1 1A le, \ 01
Property Owner Name:
Address of Property:
Telephone Number: A�� 3- 3, 0 1— C) U C'\01
Type of Work: �. SS ; c� � 0- J (\ey _
NOTE:
• The Emergency CAMA General Permit 2500 is for repairs and replacement of water -
dependent structures damaged because of Hurricane Florence and/or TS Michael. The
replacement, reconstruction and maintenance excavation activities shall conform to
current standards and rules. All work under the Emergency CAMA GP 2500 must be
made in the same footprint of the previous structure with no additions, expansions, or
enlargements.
• If any portion of a structure being replaced is within the 15' setback of the riparian line or
access area, signatures of the adjacent riparian property owner(s) must be obtained
acknowledging the notification and waiver of the setback on the forms provided by
DCM.
• Any maintenance excavation or dredging requires signatures of the adjacent riparian
property owner(s) on the notification forms provided by DCM.
Signature:
RECEIVED
JUL 2 6 2019
DCM-MHD CITY

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