74372D - Jam

CAMA / V DREDGE & FILL
GENERAL PERMIT
ANew ❑Modification [-]Complete Reissue ❑Partial Reissue
No. 743 72
A B C
Previous permit #
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 07r/ • 11190
pp� h (� , (,, ' 1 ❑ Rules attached.
Applicant Name ✓Q 1 h i Ooyi I �J / LAf 6 ► I �' I Project Location: County NQM/ /v"Y
Address 1%3 U lg"6) 0 VI t C4 Street Address/ State Road/ Lot #(s)
City WI"tr"jirlllr(I tasteA/� ZIP {.`ma-cM
Phone # (9id) Q - ailc/'GItt VP in.faubdivision ----
Authorized Agent - f /(City ZIP
Affected ❑ CW ❑ EW ❑ PTA ins OPTS
AEC(s): ❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PWs:
ORW: es no PNA yes /o
Phone # ( --T-- River Basin
Adj. Wtr. Body at /mom)
Closest Maj. Wtr. Bodyaj ujw
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MMMOMMEMENNE IN NOW
Agent or Applicant Printed Name
i
Signature ** Please read compliance statement on back of permit **
J0, 3130
Application Fee(s) Check #
Permit�/�iit::O""ffcer's Printed Name
Signature
slM Aoiq is �g7Lo o,
Issuing Date Expiration Date

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Letter of agent
I anti �rn -• have retained Mark Clements DBA, Clements
Marine Construction Inc, to make application for any and all permits needed to start
construction on the work requested for our property or properties.
By allowing Mr. Clements to make such applications I do understand that this will in no
way relieve me of any obligations to perform all work according to the building codes of
North Carolina, CAMA, DWQ or any other state and or county ordinances.
OP
Print Ram
Signature
gIn— bo 31-4-9A1 date -3-
Contact information

CERTIFIED MAIL - RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER
FORM
Name of individual applying for the permit: ' A L '
Address of property:
(Lot or street#, street of road)
(City & County)
I hereby certify the I own property adjacent to the above referenced property. The
Individual applying for this permit has described to me (as shown on the attached
drawing) the development they are proposing. A description or drawing, with
dimensions, should be provided whit this letter.
I hpve no objections to this proposal
If you have objections to what is being proposed, please write the Division of Coastal
Management, 400 Commerce Ave., Morehead City, NC 28557 or call [phone]
within 10 days of receipt of the notice. No response is considered the same as no
objection if you have been notified by Certified Mail.
Waiver Section
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift or
sandbags 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
o not wish to waive the 15" setback requirements

117
Signature
Date
2 _Print Name
Telephone number with area code

CERTIFIED M LIL REPT TURN RECEIREQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER
FORM
Name of individual applying for the permit:(i1 n� ♦�\ )r. ° 7t
Address of property:�
(Lot or slrcelM, strtN or rofd)
—
(Ciq & ('Doom
I hereby certify the I own property adjacent to the above referenced property. The
Individual applying for this permit has described to me (as shown on the attached
drawing) the development they are proposing. A description or drawing, with
dimensions, should be provided whit this letter.
/ ✓KJ I have no objections to this proposal
If you have objections to what is being proposed, please write the Division of Coastal
Management, 400 Commerce Ave., Morehead City, NC 28557 or call [phone]
within 10 days of receipt of the notice. No response is considered the same as no
objection if you have been notified by Certified Mail.
Waiver Section
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift or
sandbags 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.)
1 do wish to waive the 15' setback requirement
I do not wish to waive the 15" setback requirements

RAI
Thomas W, 1Broad-Poof Print Name
q I D _ & R6 - L4 E 110 Telephone number with area code

Data Received
Data De ../tact
CWk Fmm Name
Nam. of Pwmlt Hods
Vendor
Chack Number
Chock
amount
P—it Numbw/Cammants
Race/ t or Ralund/Roallocated
Col mnl
Column3
COMM3
ColumrN
Columns
Columns
Column7
ColumnE
Columno _
9/11/2019
Clements Marine Construction
Jam Properties / Dan Smith
First Citizens Bank
BB&T
IBB&T
5230
8585
23451
$ 400.00 GP #74372D
$ 200.00 GP #74534D
$ 200.00 1 GP #74505D
PA rat. 9168
TMc rct. 9146
ITP rct 8749
9/11/2019
and John Floyd
John Floyd
9/11/20191
_Carolyn
1 H5 Construction LLC
I Mary Travers