Butts, Brett

F' CAMA / ❑ DREDGE & FILL NO. 74465
GENERAL PERMIT A e t r Previous permit #
JNew ❑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 Com fission in an area of environmental Concern pursuant to I SA NCAC � O
CT
i ales attac�d.
Applicant Name_ , Project Location: County 4 t .T—'
Address t' ) I Street Address/ State Road/ Lot #(s)
City( N� { 1 ; State ZIP % i 1� t�
_. 47
Authorized Agent
Affected �CW )(EW 'XPTA [I ES ❑PTS
A
Affecte a OEA ❑ HHF ❑ IH ❑ UBA El NIA
❑ PWS:
ORW: yes /1"' / PNA yes /
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Agpnt or Applicant Print e Nam
Slgi„tire " Please read compliance statement on back of permit"
Signature
Application Fee(s) Check# Issuing Date Expiration Date

AGENT AUTHORIZATION FOR LAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: -S� f esr // S
Mailing Address:
Phone Number:
Email Address:
I certify that I have authorized
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: = act' ti fit —
La
at my property located at 5 /6 /V0 4
in h car 5 County.
e.
1 furthermore certify that / 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:
igna re
Print or Type Name
O c i.-
t Title
Date
RECEIVED
This certification is valid through / / MAY 01 Z019
DCM-MHD CITY

;e DACE 4T R_ IpgR�l
I hereby cart 1'y i h : f I own Woperty adjacent toLt
Property located rit (/ . , i,Nsca of Pro
on
(� (Arldresa, lot, lat k, cad, etc.,) ►.
L I in�
(t Y,31 arbodyJj
(Clty/Town andlor
The applicp1l
IocatFon
r)
N.C.
Y)
hss cescnberl to me, as shown below, the development proposed at the above
I h are! no objr ction to this proposal.
- ---___ hI,!E objection,sto-this.proposal.
DIiSCftl:1TION ANWOR DR4 IW NG OF PROPOSED DEVELOPRIEN•
(Individual pr Api gq'j ig deve,"'opment mast till in descrll don below or attacl4 a s
9
I understand tha: a i, dock, moorinWA "9"ECTION
par. g pilings, breakwater, boathouse, I-0or groin
ish o mini m se tar ce of 1Pi' from my Brea of riparian kiXess unless waived by
ish tow ' e the se tl Ira rk, you must initial the appropriate Alank below.)
�__ I do'Ni:,h t:i Waive the 15' setbick requirement. o '( I Se•K" k,
I do no t w sh tc waive the 15' ; setback requirement.
(Property Owner In`c,nnation) (Adjaceclt P
>
Print or TI
r ' ng c
<.,. City/states
i Tetep11n,
r - - -t)a
E
fe drawin41))
ust be set
re. (If you
PLtA, A'd
,ation)
l
------ f2ECE.IVED
(Reused, 1eM6Y2P 1 2019
DCM-MHD CITY

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4'I1JAClN! WPARIANI!ROKIRiY/O,WNI:;RSTATEMEW1
I hereby cell 11'tii3: rn!m prof erty adlacen: to
(Namis of property Owner) !.
property im 114
(Adds I MR, L7iocsrc, l i Ra(r��e��t-�))�� f� .
in 1� .--• - — N.C.
on
(cr1' grown and4o ror urMFI
(trlat: �rbarliy) I
The appliear hs.e. r. ?Sa taed to me, as sf rwn below, the d,'velopment pra.msed at thf above I
locatio I
1 I rw no ohje lion to this p oposal. i!
I L;:%lr objectic ns to this pro Mal.
r t, PTION L,NDlOR DRA MNG OF PROPI ISED DEVELO PMEW
(jndjvW rat F rog c i i tg drove opment mua t flit in descripfion below or id rch a s ibe c roving)
PIIl'rGP''j_
WA VIER SECTION
I understand ! !al. I; i.ier, docl,., mooring P ings, breakwater boathouse, lift, or gnai n I ast be set
back a minim r n :1:'Ir ante of 16 from my area of riparian recess unless waive+:I by le. (If you
wish to waive Ile jw crack, yc j must initial the appropriate blank below.)
I
:lo a, i;' h to wai +e the 16 se I bade requiremel L
ilo ro , [ wislh tr waive the I;, setback requir ! mennt.
xmati(ra)
0a
(Adjal:: ent Property Owner 111311
Si
:� -- -4
Print or i)pe Name ,
Mailer c, Address
:y. Lr] �n; _
rete4
ate
RECE.IVI�V-)
OR,
MAY 01 2019
mation)
I
sed 6fiWM2)
—--DGM-MHD CITY $Ifrattn'ed , I th CamScanner

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