73516D - Polen

❑DREDGE & FILL NO. 73516 A B C IUD
GENERAL PERMIT Previous permit #
New ❑Modification El Complete 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 15A NCAC Q I H , 12 O O
❑ Rules attached.
Applicant Name L AR Ry 7d L-Lo / Project Location: County B R iAA/ 5 N 1 C K
Address PA I NT Rom. DR • Street Address/ State Road/ Lot #(s) 7�4 15
City MATTNEW5 State AIC ZIP Z?104 CFAA A0V6L-510r_
Phone#(Z)254- 1¢$7 E-Mail ,/IA Subdivision LOCKW COV-4TIxY CLikc
Authorized Agent MATT Hom City SupPA-Y ZIP 29462
Affected ❑ CW XEW PTA ❑ ES ❑ PTS ' Phone # (4 I o) 8$ O - 43 8 I River Basin 14A µ a ER
❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A R ► ?
L
AEC(s): Adj. Wtr. Body OC K W OoD F71Ou..y�at man /unkn)
❑ PWS:
ORW: yes / no PNA yes / no Closest Maj. Wtr. Body A I W W
r �
in length
number
avg distance offshore_
max distance offshore
NENNI_lmmmmmwp
Flows
cubic yards
MEN
101
at ramp
h Bulldozing
MEIN'
NO NOWNEEMEN
-reline Length
not sure yes
,ratorium: ye
tos: ye: 60
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Inn 41 h A'
Agent or Applicant Printed Name
Signature ** Please read compliance statement on back of permit*
#200 #
Application Fee(s) Check #
YLER M c
Permit Officer's Printed Name
Signature
518 4011 9 /a/zol y
Issuing Date Expiration Date

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: Larry Polen
Mailing Address: 625 Raintree Dr.
Matthews, NC 28104
-Phone Number: 704-254-1487
Email Address:
I certify that I have authorized H5 Construction, LLC
Agent i Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: adding new hand rail and walkway.
relocating boat lift, new floating dock
at my property located at 3415 Channelside Dr. ,
in Brunswick
County.
l furthermore certify that / 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
Larry Polen
Print or Type Name
Titre
04 1 02 1 19
Date
This certification is valid through 1 !

I hereby certify that I own pro adjacent to LAB W V y A. c�� 's
3 q ry' `° Name of Property Owuml
property looted at t r �1.i���
on,... uC� `� r & Mdrm, Lot Mock, mod, ate.) S N.c.
Wa y) (CMyfTcwm andfor
The appffcant 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.
-SEE 4-M"4G�D
P?®�O4
SECMOW
I understand #Mt a pier, dock, mooring Riles, boat ramp, breakwater, boathous®, I`fi, or groin
must be set back a minimum distance of 15, from my area of riparian access unless waived by
nee. (If YOU wish waive the setback, you mue in6t W the appropriate blank below.)
da wish to waive the IV setback requirement.
do W wish to waive the 15, setback re Lgremnt.
(prop Owner ire on) o eR®on)P
7:
Ugnature Sie"
Print or Type Muse Print or TWe Nam
YZ
Mai Address Making Address
S U roc t LA4 1,a it ffi (�' Z S -01;p -, A)C z. T94 6 z
c��* �P94, /�o �Teephone Amtbelemaii addres Tel�pAUrnbar /emal addres
Date
!4
(Revised Aug. 2014)
*/aid for one calendar year after signature

Sheet "0"
LOCKWOOD FOLLY PROPERTY OWNERS ASSOCIATION
ARCHITECTURAL STANDARDS COMMITTEE
18 CLUB HOUSE DRIVE, SW n
SUPPLY, NC 28462
REQUEST FOR.RENOVATION APPROVAL
Homeowner: -
!
Address: 3 4-1 S G �4 h !-- Q
Phone: -I 4,154 t Li S 6. Email: � �. � � � � i"1 yC�.�o� ,. � M
Date:
12:Describe the proposed renovation:�i �'"' t
we- 1 T -
Attach appropriate documentation: architectural drawings or plans color samples, etc.
Name of Contractor:
Address:.�-
�. mail:
A ,� • �
Phone: Q�.;
Anticipated date of commencement_ .. t ` aand
completion:
Return to the above address prior to the 1 st or the 15th of the month. Requests will be considered at
the next scheduled ASC meeting. A decision will be sent, in writing, to the Homeowner. If any
ormation is required, You will be notified. A project manager will be assigned for all
further uif
approved renovations. 50

Subject Boat Lift & Dock
From Joe Geise
To: Larry Polen <[e-mail]>
Date Tue, Apr 2 2019 at 6:41 PM
Larry,
Your re -submission of boat lift/dock project was approved by the ASC. Please keep me
appraised of progress.
Joe Geise

PROJECT: 3415 Channelside
5 8'
LOCKW D F LLY RIVER
61'
7
8'
3'X32' NEW WALKWAY
8
10'x20'
12X12 GAZEBO 3'x16' RAMP FLOATER
H5 CONSTRUCTION, LLC
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Date Recelved
Date Deposited Check Fmm (Name)
Name of Permit Holder
Vendor
Check Number
Check
unt
Permit NumbenComments
Rece/pt or Retund/Realkxated
Columnl
Column2 Column3
ColumM
Columns
C.1-1
Cdumn7
ColumnD
Column9
54142019
Pole,
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0.
Pa751
47