74227D - Kaznowski

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�CAMA / J DREDGE & FILL NO. 74227 A B C
ENERAL PERMIT Previous permit #
evw ❑Modification OComplete 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 I SA NCAC
/ ❑ Rules attached.
Applicant Name �/� �QIC /A a- �/I O M�f�i� Z/V DW Project Location: County /L /y�) 4711
Address / 2.3 se4j,,� Ili e ,) _Pa,
City P ef StatOC ZIP 2�
Phone # E-Mail
Authorized Agent /17/9177-,/ -Pv✓ ,SAGJ v .v,L
Affected ❑ CW XEW 4PTA ❑ ES ❑ PTS
AEC(s): ❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS:
Street Address/ State Road/ Lot #(s)
- !� 1$2i__
Subdivision
City
ZIP
Phone # ( ) River Basin Aka,
Adj. Wtr. BodySLdli 4 O y w4� (41W/man /unkn)
- -- ... _ .11 AI'.''.I
Agent or Applicant Printe N �PermitOfficer's Printed Name
Signature ** Please read compliance statement on back of permit
.Zoq
Application Fee(s) Check #
Signature
92 %
Issuing Date ExF'rAion bate

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit.
Mailing Address, 123 Sound %hew Or
Hampstead, NC 28443
Phone Number: 919-815.5366
Email Address: PattikazttgmaB.com
Patride Kaznowsk,, Thomas KetnowsW
I certify that I have authorized matthew sawyer
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: kWWhi+g a wooden dodo W" and observatory
ar o w
at my property located at 123 Sound View Or Hampstead, NC 28443
in Pender County.
I furthermore certify that 1 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.
Pro wner Information:
Title
Date
This certification is valid throuah / 1 1 ZU/

A0 ACENI RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to Kaznowski ,s
(Name of Property Owner)
property located at 123 Sound VkW Dr. Hampstead, NC 28443
on Aft7dc lnnwastar Watrr Way (Address, PWW Lot, Blocks R etc.)
N.C.
(Waterbody) (Citytrown and/or County)
The ap cant has described to me, as shown below, the development proposed at the above
coca '
t have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(lndlvldual proposing development must till In description below orattach a site drawing)
Installing a wooden dock with and observatory area along
with a floating kayak/ canoe launch.
Site drawings are attached
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 16 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.
(Rr rtw Owner Information)
7;E c a
�
Ja
1
LAOWS�Ck
Print or Ty Name
Arms or
123 Sound View Dr
rog Address
Hwst
Hurytstud. NG 26443
�r�lrtg
rk
9roweao
1"t
Tefanhons Number/emaJ7 address
Te►e�phc
Date 1
pQfe•
'Valid for one calendar year after signature•
Information)
2)
U 1� p ri G} I
Number / emad acd mss
(Revised Aug. 2014)

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to Kaznowski s
property located at Sound
123 Sod Vkw Dr. Hamgnead, NC 2 ("N43me Of Property Owner)
(Address, Lot, Block, Road, etc.)
on Atlantic Jntr�tal water Way in Fender N.C.
(Waterbody) (CitylTown 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.
V 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)
Installing a wooden dock with and observatory area along
with a floating kayak/ canoe launch.
Site drawings are attached
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 16 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.
(Pr arty Owner Information)
cc to
S/gnalure
p�ir�c.�a C {:liznoc�S'
Print or Type Name
123 Sound View Dr
Mailing Address
Hwnp tad, NC 28443
CkylStatalzp
919-815.5366 P�vl�lrpnui�om
Telephone NumherlemaHaddress
Dale
(Adjacent Property Owner Information)
Sigrlure''�
U a iZ
Print or Type Name
v, r - pp^
Mailing Addresst
s.4J1Y—2.i�____--
Clty.'Stat&Zfp
Te"hone Numberl email address
_
(Revised Aug 2014)
'Valid for one calendar year after signature'

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Date Racelved
Date aped
Check F— Name
Name of Pemntt Holder
Vendor
Check Number
amount
FWmit NumbaiCommenta
Recelt or RelunMteaaocated
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