67926D - Glinski

nCAMA / DREDGE & FILL l I /rn ' 57926 A B
NERAL PERMIT v� Previous permit#
ew ❑Modification ❑Complete Reissue El Partial Reissue Date previous permit issued
trued by the State of North Carolina, Department of Environment and Natural Resources ri
Coastal Resources Commission in an area of environmental concern pursuant to I SA NCACy
l ❑ Rules attach�e/d.
it Name ,,� o l ���-� k-� Project Location: County N&S �M -L 1(-
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ng permit may be required by: ' bVV "A h �� Q QC 1� 6C ❑ See note on back regarding River Basin r
Local Planning Jurisdiction) -

MC Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant: LJ`� 5�' Permit #: (`7 2-4� -�
Date:
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 .
FINAL Feet
(Applied. for.
(Ant paled final
(Applied for..
(Anticipated final
Habitat Name
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
disturbance.
Choose One
includes any
Excludes any
total includes
Excludes any
anticipated
restoration
any anticipated
restoration and/or
restoration or
andlor temp
restoration or
temp impad
tempimpacts
impact amount)temp
impacts)
amount)
6 V Dredge ❑
Fill ❑
Both ❑
Other IX
Dredge ❑
Fill ❑
Both ❑
Other j]
Dredge ❑
FIII ❑
Both ❑
Other ❑
Dredge., ❑
Fill ❑
Both ❑
Other ❑
Dredge ❑
Fill ❑
Both ❑
Other ❑
Dredge ❑
Fill ❑
Both ❑
Other ❑
vicuya Ll
i Ut LJ
DUtIt LJ
VU1Cr Lf
Dredge❑
Fill ❑
Both ❑
Other ❑
Dredge ❑
Fill ❑
Bath 0
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 ❑

)ayment Proccessing Confirmation
Date Received 11/10/2016
:heck From (Name) Maritime Coastal Construction LLC
Name of Permit Holder Ron Glinski
Vendor CresCom Bank
Check Number 2360
Check amount $200.00
Multiple Permits No
Major/Minor
Permit Number/Comments GP 67926D
Receipt or Refund/Reallocated SF/2841D

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date / /—
Name of Property Owner Applying for Permit:
2gV2o?,
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)
at (my property located at)
�ah �le 6,11�, Al C 2 g y.G i
This certification is valid thru (date)
2
Property Owner Signature v Date

:r •� �Cli r.L/
ADJ3CEy-T RIPARMN PROPERTY ON'V NER STATEWNT
(FOR A PIE MOOR17VG PH-TNGSIBO4TUMBOATSOUSE)
I hereby certify that I own property adjacent to r %'Cc li` _ ? Ill; 51 i is
' (Name of Property Owner. "
p:open} located at i l
(Lot, BIock, Road, etc.)
oL+ilT L` �r. TGGi.I�" ,in N.C.
(Waterbody) (Town and/or County)
Applicant's phone #: /!l . �- 'Mailing Address: �/ —�J"�� /` )
He has described to me, as shown below, the dey elop- ent 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 (1 aom my area of riparian access unless
waived by rae. (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
(Riparian Prope �ner Information)
Signature

4 ,
NTS
/�, � 7�
y fo-j- S'rimy
2 t P-er,d,v-, s`
0c.{e- i� :� I
N & 2- q4l

■ Complete items 1, 2, and 3.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
1. Article Addressed to:
Z 1 b
A. Signature
❑ Agent
X ❑ Addressee
B./Received bb+y (Printed Name) C. li
Date of Delivery
,
D. Is delivery address different from item 1? ❑ Yes
If YES, enter delivery address below: ❑ No
3. Service Type
❑ Priority Mail Express@
❑ Adult Signature
❑ Registered MailT
I
I
�II I
I'I
II
I I II
I II I
"I
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(I
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❑ Adult Signature Restricted Delivery
❑Registered Mail Restricted
❑ Certified Mail@
Delivery
9590 9402 1364 5285 7717 75
❑ Certified Mail Restricted Delivery
❑ Return Receipt for
Merchandise
❑ Collect on Delivery
El Collect on Delivery Restricted Delivery
Signature ConfirmationT°
❑ Signature Confirmation
2. Article Number (Transfer from service label)
❑ Insured Mail
❑ Insured Mail Restricted Delivery
Restricted Delivery
toy. $500)
PS Form 3811, July 2015 PSN 7530-02-000-9053
Domestic Return Receipt