Jezioranski, Paul

CAMA / FDREDGE & FILL No. 75293
-� A B C D
GENERAL PERMIT Previous permit#
-New ❑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
}Rules attached.
Applicant Name I ! r Project Location: County
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State t
(ZIP _ /• /r'.
Phone # ('`%) ;. '
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/ CIE -Mail -.
Authorized Agent
❑EW
fI PTA OES
❑PTS
Affected .©CW
AEC(s): ❑OEA
F1HHF
❑IH ❑UBA
❑N/A
❑ PWS:
ORW: yes / no PNA yes / no
Street Address/ State Road/ Lot #(s) I I iv, f ,
Subdivision
City \ I ZIP
Phone # O River Basin
Adj. Wtr. Body -/ (nat /man Jun>r)
Closest Maj. Wtr. Body
Type of Project/ Activity
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Signature **Please read' mpliance statement on back of permit*'*
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Application Fee(s) Check#
PermitOfflcer's Printed Name
Signature
Iss. ing Date Expiration Date

GENT AUTHOR194 ION �OR_GAMA PgRMtT APPLICATION
Name of Property Owner (Requesting Permit; - }-- ��' 0 N a to -SA,
Mailing Address:
— cat e i c ko
Phone Number:
Email Address: (k) 6A
e
I certify that i have authorized i.v_'v_c f4 t-n d r,�'4 C, ,, ,rfpytj)� , LLc
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 z 4 1 WO UU6 c
in !2 SIo County. f
l 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.
`Rmperty-( Mr Inf maation:
Signature
o y-w 0 .
Print or Type Name
Title
Date
This certification is valid through

ADJACENT RIPARIAN PROPERTY OWNER STATEMENTII',
I hereby certify that I own property adjacent to K 1 _ 's
_ _ , , , t t r% � (Nam of Pr pd arty Owher)
property located at
on 01) inPd 5 e YYU N.C.
(Waterbody) (City/Town and/ r C�—
The applicant has described to me, as shown below, the development proposed at the above
01 W, 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.
�'q
(Revised Aug. 2014)
`Valid for one calendar year after signature`

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to L�l iIQ h,' I 's
(Nam of Property Owiter)
property located at � a � JJJ6L-i -Y- �)cw Dr
n 1' W \ (Address, Lot, lock, oad tc.)
-fia on .� , in _ eQ� e-rf , N.C.
(Waterbody) (City/Town and/4 County)
The applicant has described to me, as shown below, the development proposed at the above
location.
1 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 SECTI
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.
n)
(Adjacent Property Owner Information)
5i 1u�5
U
(Revised Aug. 2014)
'Valid for one calendar year after signature'

Project
Subject
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By
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