Kawecki, Lynn

L!LAMA / ❑ DREDGE & FILL No. 74446 A g / C D
W
GENERAL PERMIT Previous permit#
LJNeA ❑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 I SA NCAC �74,
1 , -
EN Rules attached.
Applicant Name li') ) ! i 1? jam I Project Location: County (,a.("j ( F 'r
Address /, (a J ('_(i (- ( I Street Address/ State Road/ Lot #(s)
City —
Phone #
State P,/ _ZIP
Authorized Agent I i e. i I 6/ f `1 d f
Affected DCW nEW t5 PTA alES ❑PTS
AEC(s): ❑OEA ❑HHF ❑IH ❑UBA El N/A
❑ PWS:
gent
Agent or Applicant Printed Name -
Signature "'Pleaseread complancestatem ntonbackofpermit•w
Application Fee(s) Check #
Subdivision
City ZIP
Phone # O River Basin/(- fi
r_ �.
Adj. Wtr. Body ��J t2vo-� \ C- i � / nai /man /unkn)
PermitOFrcer's Printed Name /
f-"/
Signature
lssulrigDaee Expiration

AGENT AUTHORIZATION FORM FOR PERMIT APPLICATIONS
Name of Property Owner Applying for Permit: � y ac n
Mailing address:
12 ySea. Gale �2 6ve
/ye4br•7 NL- 2-2�'s--70
Telephone Number: A� ''3i-6 1/37
I certify that I have authorized ALj )-ToA) (agent/contractor),
to act on my behalf, for the purpose of applying and obtaining all CAMA permits
necessary for the proposed development of VEN U I 6 1 ral(u3(rG uju(,-
at my property located at / Z4© Sea 6a fe Dr',sN New19o, T A'c-- z,?s-7D
This certification is valid through
(Property Owner Information)
4
Signature
Lynn Kau)e-c-A,,
Print or Type Name
J�
Title, co. owner or trustee for property
Date
Telephone Number
Email Address
(date).

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
hereby certify that I own property adjacent to LOW Q (--f . m 's
property located at
(Name of Property Owner)
� �, �-� �J SCQ-G-�iG�C`Q�j,L)x'�`
(Address, Lot, Block, �Qa�d, etc.
on % in Y�i C- F' � N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location.
ih" . � // 1 have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must sill in description below or attach a site drawing)
WAIVER SECTION
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.)
ire J I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
7, 3�cJ
Date
(Adjacent Property Owner Information)
S -"?35
Date
(Revised 611812012)

Date
Date
(Revised 611812012)

I hereby certify than own property adjacent to _L f m KAtiY(,(_R^ 's
(Name of Property Owner)
property located at r L4'0 r/)(2Z,,K
(Address, Lot, Block, Road, etc.)
on in I\ u k>j27k— , N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
Xn:
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
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 waiv the setback, you must Initial the appropriate blank below.)
II do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property
/Owner Information)
Signature
13n 4 reia r ,�
Print or Tilpe Name
Mailing Address) � ^3 Z �La (21J- t7,
City/State/Zip / p G 7- ?-C
Telephone Number
(Adjacent Property Owner Information)
Si nature
(401) IeAWC-ctcin
Print or Type Name
Mailing Address
'C-F VARta �p�
Telep one Number

Date
Date
b
(Revised 611812012)
N w�