Osikia, James

AMA / ❑ DREDGE & FILL N9 78425 A B CC D
NERAL PERMIT Previous permit#
@W ' EModification ❑Complete Reissue ❑Partial Reissue Date previous perm/it issued
As authorized by the State of North Carolina, Department of Environmental Quality
and the Coastal Resources Commission in an area of nvironmental concern pursuant to I SA NCAC
❑ Ryles attach ed.
Applicant Name )Ci7`l el �ir/ /l Project Location: County 4 r,
/1 2 ( 1` �e' r"A a /
L Fi i l , i State IV(-
Phone #
Authorized Agent
Affected E'qW'
AEC(s): El OEA
❑ PWS
ORW: rest/ no
"'
E-, jail
)W ,ETA ❑ES ❑PTS
❑HHF ❑IH ❑UBA El NIA
PNA yes / no
Street Address/ State Road/ Lot #(s)
72�
Phone # ( )
Adj. Wtr. Body_
Closest Maj. Wtr.
River Basin
Type of Project/ Activity
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/{gent or Applicant
Signature ** Please read compliance statement on back of permit**
_- 106S
, f A"pplication Fee(s) Check #

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
/y t
Name of Property Owner Requesting Permit: j r vnc5
Mailing Address: 4-11 3 C 2r, R_` Novel-
-J"'A kN6,Ale— Z S550A
Phone Number: 35LA- alsw
Email Address: �ir� `�cc �' anw,1I. cuvi 1 I
I certify that I have authorized 1• C (eve /C,W5 l C� -1 C9�}«'[t>�
Agent i C ntractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: geV e- L��r, row
at my property located at '-113 (^ kemryel pr1vG Fonerr,_W l SiC
in C-aAe-c-e-� 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:
Signature �)c� rrlec Ls(/S c.
Print or Type Name
Ow OQC
Title
12 ICI Ili
Date
This certification is valid through

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT �J
I hereby certify that I own property adjacent to �c�miiS S i lL.
(Name of Pro erty Owner)
property located at L{ I K'- � �ve &� i,. n
(Address, Lot, Block, Road, etc.)
an c s-i C.i nKXv In j �oliA �G % r,.� N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location.
_ x_ 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)
L'� l l I Lt13 ( Ll
LJ'A�
1? r
t')04z(-
L A M P WAIVER SECTION 1J
1 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.)
X I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner
or
address
'Valid for one calendar year after signature`
Property Owner Information)
q
d rrai'vCom
(Revised Aug. 2014)

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT`
I hereby certify that I own property adjacent to am is OSTI lL�& 's
(Name of Property Owner)
property located at 'i 13 L^S� �vr E �kg& Isle
o (Address, Lot, Block, Road, etc.)
on �y rxct^ i'ln>nr in Fw .�1.A IS(G i� �cr�.% N.C.
(Waterbody) (Cityrrown and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location.
_ 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)
L )'A
L113
t-7 `
tJoAy-
LlIS
L.) -Lc
L A /% D WAIVER SECTION ),AAJ 0
1 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 Owner Infprmation) (Adjacent Property Owner Information)
Name
..�:QraCr� sLe iUi_ 28 ... Nc, 22606
City/State�ztp City/StateJLtp
ZSL3S1 twoo q(a-�'�1—t33'7
Telephone Numb r/email address Telephone Number/email address
1 Z I t�1
Unre Date`
(Revised Aug. 2014)
'Valid for one calendar year after signature'