Shivar, Ken

969,MA / ❑ DREDGE & FILL No. 75298
A B C D
CpIENERAL PERMIT Previous permit#
MNew • ❑Modification El Complete Reissue ❑Partial Reissue Date previous permit issued
As authorized1by the State of North Carolina, Department of Environmental Quality
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
j ❑Rul sattached.
Applicant Name _ r % Project Location: County � , /
Address
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City-_-!. State ZIP
Phone # O E-Mail rr
ff �c Authorized Agent
Affected ❑CW ❑EW El PTA El ES ❑PTS
AEC(s): ❑ OEA ❑ HHF ❑ IH ❑ USA ❑ N/A
❑ PWS:
ORW: yes / no PNA yes / no
Street Address/ State Road/ Lot #(s)
Subdivision L✓
City ' / ((� ZIP
Phone # O River Basin
Adj. Wtr. Body (chat /man /unkn)
Closest Maj. Wtr. Body
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Agent or Applicant Printed Name
Printed Name ._........
Signature •* Please read compliance statement on back of permit"
Application Fee(s) Check
Signature.._. _
Issuing J. Expi ation Date

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ADJACENT RIPARIAN PROPERTY OWNER
STATEMENT FOR CAMA MINOR PERMITS
I hereby certify that I own property adjacent to ! \ C WN L� r VA r 's
(Name of Property Owner)
property located at 1 Z 4 CQ. pe 17-- rA e rcd J Lo
Address, Lot, Block, Road, etc.)
on in eMP/-4 W EC/e , N.C.
( terbody) (Town andlor County)
He has described to me as shown in the attached application and project drawing(s), the development
he is proposing at that location, and, I have no objections to his proposal.
(APPLICATION AND DRAWING OF PROPOSED DEVELOPMENT ATTACHED)
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Print or Type Name
2S2 G%S- '59)s'
Telephone Number
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Date
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AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Req
Mailing Address:
Phone Number:
Email Address:
I certify that I have authorized
>'S SUy a r O t sry Q t*a:1 CJ m
-Sr
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
i
atmy//��property located at yak rue (Cn1e/`4 jel �p er�ld cr's/e
in a �-%ere-t County. 'T�
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.
Property Owner Information:
Signature
iKe�t,,,P Lie Sh �a✓
l Print or Type Name
VW /\P %
Title
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Date
This certification is valid through