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Home My WebLink AboutMartin, CharlesCAMA / DREDGE & FILL No. 75921 A B C ) D GENERAL PERMIT Previous permit# JNew ❑Modification LJComplete Reissue ❑Partial Reissue Date previous permit issued As authorized by the State of North Carolina, Department of Environmental Quality .-I and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC �1 LJ Rules attached. Applicant Name i } i` /U 1; °� /f Project Location: County_ j i> Address Street Address/ State Road/ Lot #(s) City State ZIP Phone # ( 1 �O ),7 / - % '/ `� E-Mail Authorized Agent Affected O CW ❑ EW ❑ PTA NES ❑ PTS AEC(s): ° OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A ❑ PWS: ORW: yes / no PNA yes / no Type of Project/ Activity ' Pier Fixe Float Fing Groi Bulk Basin Boat Boat Beac Oth Sher SAV Mon Phot Wain Subdivision City —) j \z ZIP V Phone # O_- _ River Basin Adj. Wtr. Body - _ - " J _ � na _ man unkn Closest Mal. Wtr. 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NNE■ N■■■ No IN ■■■ IN No ME .61 .::....::._.0 1 A building permit may be required by: f�) �� I` ('v ( tP I ! ( ( Note Local Planning Jurisdiction). \\f r Notes/ Special Conditions "IV, -II .� Agent or Applicant Printed Name Signature '• Please read compliance statement on back of permit" Application Fee(s) Check # ❑ See note on back/regarding River Basin rules. f Permit Officer's Printer Signature /7/'//7 iTP /i Date AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION Name of Property Owner Request1Zing Permit: l �(1i �� _ icc Mo r- I ti Mailing Address: 't' (� 0ox A q,14 Ditala i c 2125 Phone Number: _q 10- v I" V 51A Email Address: 6 tindn f. a— rconVL wh oo , Gom I certify that I have authorized Agent / Contractor to act on my behalf, for the purpose of applying for and obtaining all CAMA permits necessary for the following proposed development: 1-1 D� pT 5 eQ WQ J iX 3O, -�nc�er �►e�' �- �+ li I-�q_s at my property located at in N51MIJ County. I furthermore certify that I 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: � a -4- Signature �,hAY�LS 9 mav- n Print or Type Name Title 1I11 �I1.9_ Date This certification is valid through I 1. ADJACENT RIPARIAN PROPERTY OWNER STATEMENT I hereby certify that I own property adjacent to ) � C'. h o r I Pr bmi ce 6 -h t, g Property 45tt, I bdJ Lt.j iCk lk rP (Nam Property O nar) located at I I' (Address, Lot Block, Road etc.) on _._tiJJ ((f , In Jl )CCWA n2 /'U, , N.C. (Waterbody (City own and/or County) The applicant has described to me, as shown below, the development proposed at the above `` location K I I have no objection to this proposal. tJi I have objections to this proposal. ------------------------------------ DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT Ondivldua f 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 wishp 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 9wner Information) Telephone Number/email address Date —II"15 It•11-tq Date" Information) 'Valid for one calendar year after signature' (Revised Aug. 2014) ADJACENT RIPARIAN PROPERTY OWNER STATEMENT (. I hereby certify that I own property adjacent to 066 6 MCC MOVIM 's (Name of Prpperty caner) &n property located at J�`!D QC+Ct)!G GS o /� (Address, Lot, Block, Road etc.) on Camp , in '�5neadl � rQ N.C. (Waterbody) (City/Town and/or County) The applicant has described to me, as shown below, the development proposed at the above loc on. CI have no objection to this proposal. S1 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 O ner Information) (Adjacent Property Owner Information) / A /1 l Sign tur * h1 L Flr✓'D Print or Type Name "4-1. f2 �k I L I-Ill-jg Date Date* h Arc, /email address (Revised Aug. 2014) *Valid for one calendar year after signature* �5 (o oX,4 d wic' A 1�ereo Rd, tot