69175D - Cox

�4CAMA / ❑ DREDGE & FILL
GENERAL PERMIT �0'Previous permit# A B C �D
;,,New ❑Modification ❑Complete Reissue El Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environment and Natural Resources
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC Q-7
`� ElR s attached.
Applicant Name L0 V I � t QX Project Location: County C `e�
Address to 6 ta
Street Address/ State Road/ Lot #(s)
City, { State k,, ZIP
Phone # E-Mail Subdivision
Authorized Agent - + o 41(1 IMOVtA City ZIP �.;- SC'A+-;
Affected ❑ Cw PTA ❑ ES ❑ PTS Phone # River Basin j'j----
❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A ,.
AEC(s): El PWS: Adj. Wtr. Bod. y A I VV w /' nat an unkn
RW: / o� PNA yes C.��}}�> Closest Maj. Wtr. Body
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Agent or Applic rinted Name
Signature Please read compliance statement on back of permit * .
;11 D q ►ter
Application Fee(s) Check #
P Officer's Printed Name
Sig tur
Issuing Date
Expiration Date

Date
Date
Check From
Name of Permit
Vendor
Check
Check
Permit Number/
Receipt #
Received
Deposited(Name)
Holder
Number
amount
Comments
5/9/2017
Allied Marine
Louis Cox
First
5615
$200.00
GP 69175D
JD rct. 3862D
Construction/Hal
Citizens
Fogleman
Bank

NC Division of GoaStal :tU 0- Mal€ "t IM.Pacic-Uor"Pu&v. c'.
Applicant:
Date: ✓ "LA — l
Describe below the HABITAT disturbances for the application.
. .. L. sa.. �nri itn f4* of ►r,aasurement found in vour Habitat code sheet.
Habitat Name
DISTURB'TYPE
Choose One
TOTAL Sq. Ft.
(Applied for.
Disturbance.total
• includes any
anticipated
restoration or
temp impacts),.impact
FINAL Sq. Ft.
(Anticipated final
disturbance.
Excludes any
restoration
and/or temp
amount
TOTAL Feet
(Applied for.
Disturbance
total includes
any anticipated
restoration or
ternini acts
FINAL Feet
(Anticipated final
disturbance.
Excludes any
restoration and/or
temp impact
amount
Dredge ❑ Fill ❑ Both ❑ Other
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ ` Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge[]. Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

AL*w
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue, Governor James H. Gregson, Director Dee Freeman, Secretary
Date ,7ag - / I
Name of Property Owner Applying for Permit:
Mailing Address:
b3n8 0Vf-r� 2�
I certify that I have authorized (agent) to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity) /�flLV-
at (my property located at)
This certification is valid thru (date) r Z - 3 (- ! 7
Property Owner S
a-a8-/-7
Date
400 Commerce Avenue, Morehead City, North Carolina 28557
Phone: [phone] FAX: [phone] Internet: www.nccoastaimanagement.net
An Equal Opportunity 1 Affirmative Action Employer — 50% Recycled 110% Post Consumer Paper

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGS/BOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to LO o 1 g COX, is
/ (Name of Property Owner)
property located at /7d S- kip S S .c"tl /,V
(Lot, Block, Road, etc.) /
on Jc wi✓ , in f-t 1%floc , N.C.
(Waterbody) (Town and/or County)
Applicant's phone #:��Q /� 1— �d �7 Mailing Address: 1 ZvI s
R Ali -
He has described to me, as shown below, the development he is proposing at that location, and, I
have no objections to his proposal. I understand that a pier/mooring pilings / boatlift / boathouse
must be set back a minimum distance of fifteen feet (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 not wish to waive
I do wish to waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be idled in by individual proposing development)
(Information for Property Owner Applying (Riparian Property Owner Information)
for Permit)
Signature
Mailing Address
City/State/Zip
Telephone Number
Signature Date
Print or -type Name
Telephone Number
Z /. /T
Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSBOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to /-MtS KOX is
(Name of Property Owner)
property located at 172-5' rlti4s (AV0&4 ,P0.44q
(Lot, Block, Road, etc.)
on in #AMP57-E1q 1 , N.C.
(Waterbody) (Town and/or County)
Applicant's phone #: Mailing Address:
He has described to me, as shown below, the development he is proposing at that location, and, I
have no objections to his proposal. I understand that a pier/mooring pilings / boatlift / boathouse
must be set back a minimum distance of fifteen feet (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 not wish to waive
I do wish to waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
(Information for Property Owner Applying
for Permit)
Mailing Address
City/State/Zip
Telephone Number
(Riparian Property OwnerAbffftpation)
Print or ITYpe Nam
qH W Y &1o6
Telephone Number
Signature Date Date

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