BFT Marina Village Yacht Club

CAMA / ❑ DREDGE & FILL W"WAM111K� No. 75036
A B ;'C D
GENERAL PERMIT Previous permit#
UM-EINew ❑Modification []Complete Reissue []Partial Reissue Date previous permit issued
As authoked 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 / r
'Rules attached.
Applicant Name { �' f' ( i j !Project Location: County L --
City i .l-7 StateL�4ZIP
lI
Phone #i(�) + ._ -Mail/' tt
Authorized Agent ( j 1 � n/
Affected 0CW EW , A DES ❑PTS
AEC(s): �oEA ❑HHF IH ❑UBA ❑WA
❑ PWS: /�
ORW: yes /fib PNA yes / no
Street AddrQss/ State Road/ Lot #(s) `
6
Phone #
Adj. Wtr.
Closest Mal. Wtr. Body
ZIP
Basin /'r ..(. //t
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Agent or Applicant Printed Name
Signature '** Please read compliancestatement on back of permit'*
Application Fee(s) Check#
PermitOfficels Printed Name--'--
Signature
Issuing D to I Expiration Date

AGENT AUTHORIZATION FOR CAMA PERMIT, APPLICATION
Name of Property Owner Requesting Permit: AOIJ�f
Mailing Address: 2 d2k L?
Phone Number:
Email Address: /r '�f ll o cg—,) &Lg
I certify that I have authorized C-A-A-A (2, VJ ,
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
It
at my property located at
in _ �2��LTCounty.
I 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-twated to this
permit application.
Property Owner Information:
z Snature
RoD-/4©01LL Aram C-
Print or Type Name
Title
O 7l 08 1
pate
This certification is valid through I 1.
> Fer=1VED
JUL 0 S 2019
DCM.MHD CITY

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to L"Ulu) tv.S s
P l,t�> �w (typmggfroperty Owner)
property located at �--�1' (ALL
(Address, Lot, Block, Road etc �.)
on LA�V ue kl " in IZ P u s! �' N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
d ca
I have no objection to this proposal.
LLiave—otjection�-to_this_pr_oposaL
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
RECEIVED
JUL 0 8 2019
WAIVER SECTION
TY
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or st?t
back a minimum distance of 15' from my area of riparian access unless waived by me. (If you
wish waive the setback, you must initial the appropriate blank below.)
I do wish to waive the 15' setback requirement.
1 do not wish to waive the 15' setback requirement.
(Propert r Owner Information)
(Adjacent Pr e ry Owner Information)
Si?re
Signa e
Prin t,cr TYP darn
Print or 574—
Type
x � rr 4
Maili Address
N 70
Mailin Addres
13P.t)7Z f�C 2g-l�n
crye�n��
�l" �/z ,14-71 3
City/State/Zip
6
Tale ope u/m¢
(
Telephone Number/ V
Date EI
Date
(Revised 611812012)

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to
property located at
1 VVC'
Iy
WJ 's
(Address, Lot, Block, Road, etc.)
on �r G� �k in Fq c29Q7— , N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
I ob do
I have no objection to this proposal.
__--�tatioobjQQtion�to this_pr_opas.aL--_
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
�i >za
qtk Cb'--
WAIVER SECTION
Ur OAC
I 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.)
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information) (Adjacent Property Owner Information)
X)
MailingO
J�ddress v f' , ^� 2-VS
Csw nv.�c , �lJ
ty/S ate/Zip
����
lep one fyiupbgr�� L�
Date ((
Signature
)2,2f��
Print or Type Name
Mailing Address
City/State/Zip
Te/ephoT Number RECEIVED
o>/©,_7 �6/_9
Date
JUL 0 S tu19
(Revised 611812012)
DCM-MHD CITY

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0 8 2019
A DCMNV4D CITY