67270D - Addonisio

AMA / El DREDGE & FILL I �!�" /
C.t!�NERAL PERMIT 141
Previous/permit# A B
❑Modification ❑Complete Reissue El Partial Reissue Date previous permit issued
•ized by the State of North Carolina, Department of Environment and Natural Resources )
:oastal Resources Commission in an area of environmental concern pursuant to I SA NCAC - l / I1 iJb
❑ Rules attached.
Name, '' p� +�dd0� ; U Project Location: Countyris
,, E I) Street Address/ State Road/ Lot #(s)
J Ur ' State AJ C ZIP Z. 8q
1 510 E-Mail Subdivision
�d Agent b il - City r ZIP Z y
❑ CW VEW WPTA ❑ ES ❑ PTS Phone # ( ) River Basin
❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A Adj. Wtr. Body 41V nat n
❑ PWS:
Closest Ma Wtr. Body-- 7
yes)/ no PNA /,;C�/ no i' y
Project/Activity +7ict 'v`.^n ;1i�- `t� FXL[1-`i qo) st 4-1
(Scale: I
:k) length
k tform(s) l Z X 4,`
'latforrr(s) -
igth
nber
I/ Riprap b
distance
K distance
annel
is yards_
Ip
;e/ Boatlift
Length - -45
not sure yes
� gom
1­1.,
I .. _-mow...,.
W
um: n/a yes (no ` i
es no I
attached: yes no -- --
ig permit may be required by: OS,p Ui
_ocal Planning Jurisdiction) i
❑ See note on back regarding River Basin rt

NC Division of Coastal Mgt. Habitat Impact Comp
Applicant: C. (tv, kqI&;s=o
Date: I1 l0 16
Describe below the HABITAT disturbances for the application.
All values should match the name, and units of measurement found in your Habitat code sheet.
TOTAL Sq. Ft.
FINAL Sq. Ft.
TOTAL Feet
FIN
(Applied for.
(Anticipated final
(Applied for.
(Ant
DISTURB TYPE
Disturbance total
includes any
disturbance.
Excludes any
Disturbance
total includes
disti
Excl
Habitat Name
Choose One
anticipated
restoration
any anticipated
rest
restoration or
and/or temp
restoration or
tern
ternimpacts)
im act amount)
tern im acts
amc
Dredge ❑ Fill ❑ Both ❑ Other J
"'
3 1p
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

'ayment Proccessing Confirmation
)ate Received 11/10/2016
heck From (Name) Gerald Addonisio
flame of Permit Holder Eileen & Gerald Addonisio
Jendor Coastal Bank & Trust
heck Number 1035
heck amount $200.00
Multiple Permits No
Major/Minor
Dermit Number/Comments GP 67270D
teceipt or Refund/Reallocated BS/2220D

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date / V O L) > )(:57
Name of Property Owner Applying for Permit: '
E 2�k�,Q Isr-7- ()
Mailing Address:
/ 2-1- c 0 1 a-� T� �� �-8y -,i s
I certify that I have authorized (agent)b -75f" to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity) F� �� /W �� 2X I ��E�-)
at (my property located at) 1:2-
I- c o*,it:A) � —UK , �/o ff� j�4
This certification is valid thru (date) W � f b) FC4 / 0. /
JAI 161+�
Property Owner Signature Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to �'� i =� �� 5 O 's
_ � l {Name of Property Owner}
property located at _ ? �—� , ��-�c ,�'�►�ht _ —
(Address, Lot, lNock, Road, etc.)
on in N C.
(Waterbody) (Cifyffown Whdior County)
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 proposa,
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
Individual proposing development must fill wq description below or attach a site awing)
l4+
o WAIVER SECTION
understand that a pier, docZk, ooring pilings, breakwater, boathouse, lift, or groin must be set back
minimum distance of 15' from my area of riparian access unless waived by me. (If you wish to waiv,
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
(Adjacent Property Owner Information;
I At,l.� i�► � _
Sigrtat
Tariv t. _
Print or Typ Name
t C V nL. --r-k' t\"4r,
Mailing!` f

ADJACENT RIPARIAN PROPERTY OWNER_ STATEMENT
I hereby certify that I own property adjacent toe,( At, t , ©h4 `
(Na of operty Owner)
property located at _ -C-
(Address, Lot, Bloc ,, Road, etc.) '
on in 'eV-6
e ` , N.C.
(Waterbody) (City! own and/or un )
The app cant has described to me, as shown below, the development proposed at the above locatio
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(individual proposing developmenL must fill y description below or attach a site drawing)
� �,,,� •.� �136x
f�..
or' f
�0Us�
RaRD WAIVER SECTION
i understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set bac
minimum distance of 15' from my area of riparian access unless waived by me. (If you wish to wz
the setbaX,you must initial the appropriate blank below.)
�.gI do wish to waive the 15' setback requirement.
1 do not wish to waive the 15' setback requirement.
(Oro ,perty Owner Id rmation) r—.� (Aiken o e e ormation)
Signature..
Print-_oror,Tyg� Name Pnn{ or Typ . amg y