Katz, Philip

A/
®�CAMA / ❑DREDGE &FILL No 71630 A B i.. C:- D
GENERAL PERMIT Previous permit#
!3New ❑Modification ❑Complete Reissue ❑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
O Rules attached.
Applicant Name Project Location: County
/
Address (! ?
City State :'b ZIP '
Phone # O E-Mail
Authorized
AAffected ❑CW ❑EW ❑PTA ❑ES ❑PTS
Affecte ❑OEA ❑HHF ❑IH ❑UBA ❑N/A
❑ PWS:
ORW: yes / no PNA yes /I no
Street Address/ State Road/ Lot #(s)
Subdivision I
CityZIP
Phone # O I River Basin A/, r I .!
Adj. Wtr. Body �'�s� nat man unkn
Closest Maj. Wtr. Body
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Agent o�AppVc,ant Printed Name
Sigrlature '`7Please read compliance statement on back of permit**
Application Fee(s) Check #
Permit Officer's
o
Date

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RECEIVED
JUL 13 2018
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DCM-MHD CITY
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AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: lJkIIZ_�p j! / 1 ' 2-
Mailing Address:
Phone Number:
Email Address:
I certify that I have authorized
a 6?1-- l0/g
/ 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 _1
in _County.
I furthermore certify that 1 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
Pb'it.IP hl627-2—
Print or Type Name
Title
Date
RECEIVED
This certification is valid through i ' i l j 7 /d i t JUL 13 2018
DCM-MHD CITY

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to P&Ll. tom% $ 1YN13'6 rJ"U&N 's
(Name of Property Owner) ,_,
property located at
on
ss, Lot, Block, Road, etc.)
in lV41,.,/_%Z,zCk4z N.C.
(City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location.
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)
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.
(Property Owner Information)
�>
Sign ure
Print or Type Name
. S-aL)4G MZ-L' 911aW '
Mailing Address
t'Ze/ 2=&9
City/StatelZip
a<,I-or,f/-/()i& //7'YTZ.DLrNr�.N.V if�I% c1�
Telephone Numbe /email address
?/'Sod-) ,C3
Date
(Adjacent Prop7ety Owner Information)
w+
Signa urn
/yon/!s 1 tL4t
Print or Type Name
Soo? PAYwei4rN CT
Mailing Address
n/FG) 1-30W , A/ c .x frS6a
City/StatelZip
2f2'GJG-3s'3�
Telephone Number/email address RECEIVED
3-
Date *
(Revised Al AU 4�01$
*Valid for one calendar year after signature`

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to
property located at
of Property Owner)
<7 rn OF
I
'(Address, Lot, Block Road, etc.)
on /�' , 7h)az.� (I eiY",4 in NgiEK' A./ , N.C.
(Waterbody) City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location
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)
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.
(Property / ner Information)
Signature �' n
nature
(Adjacent Property Owner Information)
SAi natur
�.,nE� �>�Cf
Print or Type N
-6 ame
�1 ""?,Je,;7� Cyr
M�%`'� hl�7 � Z �
4-M G6 -� =25< 7 (� c� ��f
Teleph Nunt)�aber/email address
�0/,2v i 77 RECEIVED
(RevisedA944 20)2018
*Valid for one calendar year after signature*

Description and Drawing of Proposed Work
Property Owner:
Section Number: 0C L1oot Num�bbeer: ..�fa x
Owners Name: R&L,10
Address:
Telephone Number:
E-mail Address:
Contractor: Company Name: Cp le- P j9 K � —2-le . 6015 MIC—V %/v
Contact Person: LyyX f e,,
Address: / k p, J \\ E A U yF0R T
Telephone Number: '2 2u2 Y:— l-f % % Q
E-mail Address: Cbl k.:rA 1q&O le- C.- M g (rl /a t1- , (' OA
Detailed description of proposed work:
DIP A19PA'�.aX'IMn-7eL? Go ne �f� oW.p4 Mjvlri 1.1'/k
47` /N !?CcoR(iG/s(if� ftlllH ��6� /7%Irh"�tJ D(��i/lh�F�_
I�kFGY� rr M&F-Peh&, (Ail r -tom -1t7 IM/ l P>/V At,19k6-.W TO
!M° 'rAMC-S L�(Ty &T7H4Ri2i if !'G /'r% l✓ 7N1�� p�j%37r t�;iAl i 6P
"To -scale" drawing of proposed wor : � 4 ?/�.. /tijU7h'(ift.!?"Lr"C1 L.-[J�i/4�'!U!✓,
RECEIVED
JUL 13 2018
DMA—M14D CITY

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RECEIVED
JUL 13 2018
DCM-MHD CITY

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JUL 13 2019
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