73523D - Kirby

XCAMA / DREDGE & FILL
� GENERAL PERMIT
AINew ❑Modification El Complete Reissue
No. 73 523 A B c
Previous permit #
❑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 07 H • 12 0©
❑ Rules attached.
Applicant Name MARK J4%F!S L Project Location: County 1RL',t/5w I C K
Address 34.24 Qu-Lcyu►ra- F-4> Street Address/ State Road/ Lot #(s) 1 754
City RA , K-ica F1 StateA[C, ZIP Z 7L 03 C A A R LOT TF
Phone # (9 IJ) 4-22- 3" E-Mail /V/A Subdivision
Authorized Agent MA -Ur µ OW City &LePrAl &-Ae N ZIP 2 7 4 & 2-
Affected ❑CW XEW IXPTA DES ❑PTS �iF'�T Phone # ( 10) >!'go-43$) River Basin 1 UM�gP
AEC(s): ❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A Adj. Wtr. Body C ANA iL, (nat ma /unkn)
❑ PWS:
ORW: yes / no PNA yes / no Closest Maj. Wtr. Body -A j W W
Type of Project/ Activity - nJ STiU A, Atk i f oA i ll- wT F NGt R PI EQ- To
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A building permit matey a equired by: N0L-T) VA/ C-AC' hl ❑ See note on back regarding River Basin rules.
( Note Local Planning jurisdiction)
Notes/ Special Conditions of N , 1 zc>c) 11..1i7 ALL 07NE2 LOCAtr -1 ETA ; r
A.t/D FEDEZAt_ '2'F' 4r I^L s-7')OJ1/S A PPLY
yv\vj�t-tJA00.,
Agent or Applicant Printed Name
Signature ** Please read compliance statement on back of permit*
4 2(-3o -4 2zG `1
--r4 '� M c- GK
PermitOfficer's Print ame ,(�
/. /._ / L C 4
Application Fee(s) Check
a
Signature 0 U
'+ A &A
Issuing Date Expiration Date

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NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue Braxton C. Davis Dee Freeman
Governor Director Secretary
AGENT AUTHORIZATION FORM
Date: Z- t'01
Name of Property Owner Applying for Permit: Name of Authorized Agent for this project:
w�h►2.1L {��I�-R�� H5 Construction, LLC
Owner's Mailing Address:
IZiv-E71 eq 414-�0 C- _1:1-609
Phone Number (glot) 42L- ?,00 t
Agent's Mailing Address:
2164 Holden Beach Rd.
Supply, NC 28462
Phone Number( 910) 8 8 0- 4 3 81
certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
for and obtaining all CAMA Permits necessary to install or construct the following (activity):
For my property located at l34- G4-(AM--I-oTQ5: 51'-
This certification ' vali ru (date) 5 f t
Property Owner nature
2.2m.let
Date
127 Cardinal Drive Ext. Wim;ngton, NC 28405
Phone: [phone] \ FAX [phone] Infernel w:ow.nccoastaimanagement net
011C
NAort hCarolitia
An Fq" OpWorty t A7fitm11we A41-W rd*yef

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that i own property adjacent to Mark Kirby 's
property located at 134 Charlotte St. (Name of Property Owner)
(Address, Lot, Block, Road, etc.)
on canal in Holden Beach
(Waterbody) (City/Town and/or County)
N.C.
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)
Install boat lift and walkway
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.
(Property
i do not wish to waive the 15' setback requirement.
rmation)
Signature��I
Print or Tye Name
Mailing Address si�t�t G-il , C.
Ci4vState/Zr
kt&4—i My3 & E C• Oy o. Gc7yK..
Telephone Number/email address
- 2.2-1. lg
Date
*Valid for one calendar year after signature*
(Adjacent Property Owner information)
Signatur
Ash14Q Min Drt
Print or Tyfde N me
Mng Address
Elk 0,; !*c h -iG lc 0-
CityistatelZ p hu
Telephone Number / email address
il-3-71),-%
Date*
(Revised Aug. 2014)

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
l hereby certify that I own property adjacent to
Mark Kirby
I
Property located at 134 Charlotte St. (Name of Property Owner)
on canal (Address, Lot, Block, Road, etc.)
in Holden Beach N.C.
(Waterbody) (City/Town andlor County)
The applicant has described to me, as shown below, the development proposed at the above
Io o .
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)
Install boat lift and walkway
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.)
l do wish to waive the 15' setback requirement.
-,- 411- 1 do not wish to waive the 15' setback requirement.
(Property
nformation)
SdgYlAttlPe��
Print or Tye Name
Mading Address
imt & , ri C-
City/Stat�e/Zp-
V- l ca..6�`�++�t v1 Cal 1 C,1-0 V D .
Telephone Number / email address
Z .
Date
*Valid for one calendar year after signature'
Owner Information)
ALAC ,4,dw,( A)
Print or Type Name
-- 0(t, j CAw� CD-r D2,V,-
Mailing Address
A t�t�t s gu�G
City/StatelLip i ,
ti Z go 75-
Tele hone Number / email address
777 S04604AA Jg1 4rR(::eA _coin
Date *3 ` Z7 - / 9
(Revised Aug. 2014)

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26'
Holden
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20'x10'
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Existing
4'x6'
50'
134 CHARLOTTE - KIRBY
PROJECT: 134 Charlotte St., Holden Beach
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CHARLOTTE STREET
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Not to scale

Date R--W-d
Defs DP,,Iftd
Check From Nsma
Name of Permit Holder
V—dor
Check Number
amount
Pwmlt NumbenComments
Receipt or RetunMb Nmsted
Columnl
Column?
I
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Columns
ColunW
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