67953D - Kemeny

NC Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant:
Date:
Permit #: G7cr5`,�-
Describe below the HABITAT disturbances for the application. All values should match the name, and units of measureme
found in your Habitat code sheet.
Habitat Name
DISTURB TYPE
Choose One
TOTAL Sq. Ft.
(Applied for.
Disturbance total
includes any
anticipated
restoration or
temp impacts)
FINAL Sq. Ft.
(Anticipated final
disturbance.
Excludes any
restoration
and/or temp .
im act amount
TOTAL Feet
(Applied for.
Disturbance
total includes
any anticipated
restoration or
temp impacts
FINAL Feet
(Ahticipated fi
disturbance.
Excludes any
restoration an
temp impact
amount)
Dredge ❑
Fill ❑ Both ❑ Other
(
Z `
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 ❑
Dredge ❑.
Fill El 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 ❑

layment Proccessing Confirmation
)ate Received 12/8/2016
:heck From (Name) H5 Construction, LLC
game of Permit Holder John Kemeny
✓endor BB&T
heck Number 1804
heck amount $200.00
Multiple Permits No
Major/Minor
permit Number/Comments GP 67953D
teceipt or Refund/Reallocated SF/2849D

C
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:
3me of Property Owner Applying for Permit: Name of Authorized Agent for this project:
Cr ,1 Ste' V C4- L r`
wner's Mailing Address:
8 _Z-_
Agent's Mailing Address:
-7-3`3$_sc,1- 11 s+^gyp
v rC..-
lone Number (g(ei) L22,1 -A L-I -1I Phone Number (Gl4)_9Z7- (Pj(ofo
ertify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
and obtaining all CAMA Permits necessary to install or construct the following (activity):
r my property located at Ze LLKA 5 Ssge NG 7-3 y Lq
s certification is valid thru (date) I( � � �t 7
Property Owner Sign a Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
' s
I hereby certify that I own property adjacent to (Name of Property caner)
property located at IA Le 6L06k Su l
r
(Address, Lot, Block, Road, etc_.) ,
on .r1 G�`t in N.C.
(Waterbody) (City/Town and/or County)
The applicant 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 development must fill in description below or attach a site drawing;
S{' e Ej vt C �v✓ e d✓Zu-�%
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, it, or gro
must be set back a minimum distance of 15' from my area of riparian access unless waived i
me. (If you wish to waive the setback, you must initial the appropriate blank below.)
� A do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
i 4 �� r
V.-
Print or Type Name
Mailing Address
(Adja ent Prop Owner Information)
gnatu
I�s� �
Print or `ype N ame 1
� I �- JC•i"t,ci�'C'G� tling Address �t

ADJACENT R(PARM PJ!QPERTY 0 NER BTAT_ EMENT
I hereby certify that 1 own property adjacent to ot"N% r� Ke-MeA Is
Property located at -� ^ ton A ,7— � (Na 4 of Prop" er)
�
- (Address, Lot, Block, Road, etc.)
On .G'..�'d(�i a , in _f. j'-ga in i e " �=' .In
(WAY) (City/Town and/orCounty)
The applicant has described to me, as shown below, the development proposed at the above
1 have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
Ondividual prOPOsing deve/apment must rill in descr4Wonbelow or attach a site drawing)
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. (jf you wish to waive the setback, you must initial the appropriate blank below.)
`� 1 do wish to waive the 15' setback requirement.
1 do not wish to waive the 15' setback requirement.
(Pr party Owner Information) (Adj Pro arty Own r ,ration
rgoatweJ
---S_�gnatur
Pd Tit ar Type Name Print or T +
Mailing Adjdress j j J �q�ling A dress �y

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