Kiley, Patrick

NCAMA / ❑ DREDGE & FILL N. O O p
.•. %8408 A B C D
GENERAL PERMIT Previous permit# %'
❑New ❑Modification LComplete 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
I ❑Rules attached.
Applicant Name ,( C} f t i E Nil Project Location: County t
Address F s Street Address/ State Road/ Lot #(s) _ I
City "TC State I ZIP
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Phone # (�_) � �' :%f'%'1E_Mail Subdivision
—
Authorized j V j C A Ah_. ; �" ZIP
Authorized Agent �`��� -ti �� v,L' t : _�� � r ;� � City ��
Affected ElCW MEW ;O PTA ❑ES ❑PTSJ Phone# ( )T River Basin
AEC(s): �OEA OHHF ❑IH ❑UBA ❑N/A Ad' W B d j } 'o, (natA/man /unkn)
❑ PWS:
ORW: yes / no PNA yes / no
Type of Project/ Activity
Pier ( c
Fixe
Float
Fing
Groi
Bulk
Basin
Boat
Boat
Beac
Oth
Shor
SAV
Mor
Phot
Wai
A building permit maybe required by: _ rt
( Note Local Planning jurisdiction)
Notes/ Special Conditions " f
Agent or Applicant Printed Name
j. tr. o y
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❑ See note on back regarding River Basin rules.
Signature '`Please read compliance statement on back of permit"
Application Fee(s)
Check#
Date

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: PjQ t r i c k
Mailing Address: {h�CYLa=) L
Phone Number: t/1 . I-S i v 6
�ty3 y i" SSA`-1
Email Address:
I certify that I have authorized I n v
Agent/
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: -5c 1 y L ; ,l' t
at my property located at 'Z`ji Z Y)? l I J &'Leg K, Y- v ;�,n
in G & e>j• County.
/ 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.
Property Owner Information:
p Si nature
Print or Type N, me
Title
Date
This certification is valid through