66616D - Kozlowski

]CAMA / ❑ DREDGE & FILL
GENERAL PERMIT �1
New ❑Modification ❑Complete Reissue El Partial Reissue
Previous permit #
Date previous permit issued
•ized by the State of North Carolina, Department of Environment and Natural Resources --7 ) i
:oastal Resources Commission in an area of environmental concern pursuant to 15A NCAC ' 1 `
jj ❑ Rules attached.
t Nam 4 oo f i IG1�- flZ t U W5 f Project Location: County �; '
Street Address/ StateRoad/ Lot #(s)
5 State ZIP �---'V��ad
1 - E-Mail _ - - Subdivision-
ed Agent City ZIP 7 M .yi
❑ CVN f A >s ❑ PTS Phone # River Basin i1 w
❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A I 9
ElPWS: Adj. Wtr. Body (� % ! 6`? n3f r
yes PNA yes / 'no Closest Maj. Wtr. Body Vl/, fi
' Project/ Activity
igth
nber
I/ Riprap length
distance offshore
x distance offshore_
annel \
iic yards_
ip
se/ Boatlift
Aldozing
a ■■ cam■■■�■■
- ■■■ ::■�:: mil:`-;���.lir■■
■ 111MMM■■/1/ ME O■ ate■ ®■

NC Division of G®a6tal l+ 9t. Habitat impact, computer Sheet
)iicant:
p
Ite:
,scribe below the HABITAT disturbances for the application.
I values should match the name, and units of measurement found in your Habitat code sheet.
TOTAL Sq. Ft.
for.
FINAL Sq. Ft.
(Anticipated final
TOTAL Feet
(Applied for.
FINAL Feet
(Anticipated fina
DISTURB TYPE
(Applied
Disturbance.total
disturbance.
Excludes any
Disturbance
total includes
disturbance.
Excludes any
abitat Name
Choose One
includes any
anticipated
restoration
.
any anticipated
restoration and/
temp impact
restoration or
and/or temp
restoration or
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑
Fill ❑
Both ❑
Other ❑
DredgeEl.
Fill ❑
Both ❑
Other ❑
Dredge 171
Fill 171
Both ❑
Other 11

t McCrory
overnor
NCDENR
North Carolina Department of Environment and Natural Resources
N.C. Division of Coastal Management
AGENT AUTHORIZATION FORM
Date:
ne of Property
�Owner Applying for Permit:
ner's Mailing Address:
31Z 414-172ES80WO CT
qZ /
?75 y�
ail: 42>ZL oW.Se/ 4,4"w/Z. Cow
one (Ml)�M '�lsa?b
John E. Skvarla, III
Secretary
Name of Authorized Agent for this project:
Agent's Mailing Address:
Email:
Phone
�rtify 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):
,DeZ<- TG Se6-`S D-/
T 4G Af1/y
my property located at ,�7�?,3 AleZ`G✓l�'.5
/vG &y60
s certification is valid 1 year from (date)
/_ --/ -- /(1,

ADJACENT RIPARIAN PROPERTY OWNER
STATEMENT FOR CAMA MINOR PERMITS
I hereby certify that I own property adjacent to /L/ s
�J G� (Name of Property Owner)
property located at / S / 6?11Qa1z,fC.e 0Z
Address, Lot, Block, Road, etc.)
onFVU,4,Z-U aXb,a-C in '5ia.40S T"2Y N.C.
(Waterbody) (Town and/or County)
He has described to me as shown in the attached application and project drawing(s), the development
he is proposing at that location, and, I have no objections to his proposal.
(APPLICATION AND DRAWING OF PROPOSED DEVELOPMENT ATTACHED)
/Sigpdture
Print or Type Name
Telephone Number
Date

ADJACENT RIPARIAN PROPERTY OWNER
STATEMENT FOR CAMA MINOR PERMITS
1 hereby certify that I own property adjacent to _/IiCi�/i 2Q /1yZL awS.�C/ I
% 93 0`cP (Name of Property Owner)
property located at j2- e114101 ell ,Iya/t es D/Z
Address, Lot, Block, Road, etc.)
on in _ SI-ItAO-S , N.C.
(Waterbody) (Town and/or County)
He has described to me as shown in the attached application and project drawing(s), the development
he is proposing at that location, and, I have no objections to his proposal.
(APPLICATION AND DRAWING OF PROPOSED DEVELOPMENT ATTACHED)
Signature
A7'1owy l
Print or Type Noe
910- 3g;2
Telephone Number
Date

ADJACENT RIPARIAN PROPERTY OWNER
STATEMENT FOR CAMA MINOR PERMITS
I hereby certify that I own property adjacent to /J�C��'/f2/J A041- ,s
(Name of Property owner)
property located at %�� /��Q�y/G'1� '5yalt�-s /o/1
Address, Lot, Block, Road, etc.)
on /&e-A110S &1,4,g e- in Sllt4.9s A71-tz, N.C.
(Waterbody) (Town and/or County)
He has described to me as shown in the attached application and project drawing(s), the development
he is proposing at that location, and, I have no objections to his proposal.
(APPLICATION AND DRAWING OF PROPOSED DEVELOPMENT ATTACHED)
�gnature
11) 7' 6 Oi z J"rn F
Print or Type Na
10 - 38a - Soo
Telephone Number
/6 aal c'
Date/

Locality
GENERAL INFORMATION
Permit Number
LAND OWNER
Name
Address C'i��e,� sHa/��S ��
City <Skzys State I'llC Zip 2,6��U Phone 1 - X�,
AUTHORIZED AGENT
Name
Address
City
State Zip Phone
LOCATION OF PROJECT Z�'�4-/Y�AW0� sG --5 Z)IZ
(If not oceanfront, is waterbody natural or manmade?)
DESCRIPTION OF PROJECT L-:�-XTFNQ 671Y15711&1 , 04D Tb /7
AREAS OF ENVIRONMENTAL CONCERN (AEC) CLASSIFICATION
(To. be filled in by the Local Permit Officer prior to completing application.)
Ocean Hazard Estuarine Shoreline ORW Shoreline Other
PROPOSED USE
y" Residential Commercial/Industrial Other
SIZE OF BUILDING IN SQUARE FEET
Size of other impervious or built upon surfaces (such as driveways, etc.) within 75 feet of the shoreline (`
of an ORW shoreline)
SIZE OF SITE IN SQUARE FEET
OTHER PERMITS MAY BE REQUIRED ... Zoning, Drinking Water Well, Septic Tank (or
_. sanitary waste treatment system), Burning, ER

STATEMENT OF OWNERSHIP
I, the undersigned, an applicant for a CAMA minor development permit, begin either the owner of property in
an area of environmental concern or a person authorized to act as an agent for purposes of applying for a
CAMA minor development permit, certify that the person listed as landowner on this application has a sig-
nificant interest in the real property described therein. This interest can be described as follows: (check one)
an owner of record title, Title is vested in Gl✓S61040 , see Deed Book 1_/Z yg
page 836 in the 911.5Zd k1 County Registry of Deeds.
an owner by virtue of inheritance. Applicant is an heir to the estate of
probate was in
County.
if other interest, such as written contact or lease, explain below or use a separate sheet and attach to this
application.
NOTIFICATION OF ADJACENT PROPERTY OWNERS
I furthermore certify that the following persons are owners of properties adjoining this property. I affirm that i
have given ACTUAL NOTICE to each of them concerning my intent to develop this property and to apply for
a CAMA permit.
(Name) (Address)
T.Q.n/�/�
3U� �7RFC7d/L�
�>).
Gy/Gi9ii/l %G✓� M
2'5y05—
(2) XiY�AkAll 1.94 L
/OORyi1eella1O©D
/1X1
15-6 50141�11GL lf/e
1245ry6
(3)
(4)
FOR DEVELOPERS IN OCEAN HAZARD AND ESTUARINE HAZARD AREAS:
I acknowledge that the land owner is aware that the proposed development is planned for an area which may
be susceptible to erosion and/or flooding. I acknowledge that the local permit officer has explained to me the
particular hazard problems associated with this lot. This explanation was accompanied by recommendations
concerning stabilization and floodproofing techniques.
PERMISSION TO ENTER ON LAND
I furthermore certify that I am authorized to grant and do in fact grant permission to the local permit officer
and his agents to enter on the aforementioned lands in connection with evaluating information related to this
permit application.
This application includes: general information (this form), a site drawing as described on the back of this ap-
plication, the ownership statement, the AEC hazard notice where necessary, a check for $50.00 made payable tc
the locality, and any information as may be provided orally by the applicant. The details of the application as

SITE DRAWING/APPLICATION CHECKLIST
Please make sure your site drawing includes the following information required for a CAMA minor develo
ment permit. The drawing may be simple and not necessarily to scale. The Local Permit Officer will help y
if requested.
PHYSICAL DIMENSIONS
label roads
label highways right of ways
label local setback lines
label any and all structures and
PHYSICAL CHARACTERISTICS
driveways currently existing on property
draw and label mean high water mark (MHW)
draw location of septic tank or filter field
If you will be working in the ocean hazard area:
draw and label dune ridges (note height)
draw and label toe of dune
identify and locate first line of stable vegetation
draw and label setback line under CAMA
draw and label topographical features (optional)
If you will be working in an estuarine shoreline area:
draw and label landward limit of AEC
describe terrain (slope)
DEVELOPMENT PLANS
draw and label areas that will be disturbed
if a house is to be placed on lot, describe location of house
note size of piling and depth to be placed in ground
draw and label all areas to be paved or graveled
describe composition of surface
note and list fully all trees and vegetation to be removed or relocated
show landscaping
NOTE TO APPLICANT
Have you:
*completed all blanks and/or indicated if not applicable?
*notified and listed adjacent property owners?
*included your site drawing?
*signed both application and statement of ownership?
*enclosed the M.00 fee?
*completed an AEC Hazard Notice, if necessary?
FOR STAFF USE
Site Notice Posted Final Inspection Fee Received
Site Inspections

'ING/APPLICATION CHECKLIST
•a
the following information required for a CAMA minor development permit.
y
pncsted.
APPLICATION FOR
r'
r,FTA!
CAMA MINOR
o�
DEVELOPMENT
id driveways currently existing on property
PERMIT
✓atcr line (contact LPO for assistance)
In 1974, the North Carolina General Assembly passed the Coastal Area Management Act
cwaler system
(CAMA) and set the stage for guiding development in fragile and productive areas that
border the state's sounds and oceanfront. Along with requiring special rare by those who
ocean hazard area:
e General Assembly directed the o astal Resources Commission
build and develop, tile C
dune ridges (include spot elevations)
e ridge
(CRC) to implement clear regulations that minimize the burden on the applicant.
tuns
ate first line of stable vegetation lcontact LPO for assistance)
This application for a minor development permit under CAMA is part of the
erosion setback line (contact LPO for assistance)
topographical features (optional)
Commission's effort to meet the spirit and intent of the General Assembly. It has been
designed to be straightforward said require no more time or effort than necessary from
coastal shoreline area:
the applicant. Please go over this folder with the Local Permit Officer (LPO) for the
he
171
overhang as a dotted lint around the structure
locality in which you plan to build to be certain that you understand what information
9
landward limit ofAEC
or she needs before you apply.
D
I all wctiand lines (contact GPO for assistance)
r"
I the 30-foot buffer line
Under CAMA regulations, the minor permit is to be issued within 25 days once a
complete application is in hand. Often less time is needed if the project is simple. The
process generally takes about ig days. You can speed the approval process by making
;truclures
certain that your application is complete and signed, that your drawing meets the
I be disturbed and/or landscaped
specifications given Inside and that your application fee Is attached.
to be placed in ground
a paved or graveled
Other permits are sometimes required for development in the coastal area. While these
d
are not CAMA-related, we urge you to check with the Local Permit Officer to determine
which of these you may need. A list is included on page two of this folder.
We appreciate your cooperation with the North Carolina Coastal Management Program
and your willingness to build in a way that protects the resources of our beautiful and
ated if not applicable"
productive coast.
rty owners'
Coastal Resources Commission
Division of Coastal Management
., if necessary' (Must be signed by the property owner)
a M
-i
n
FOR STAFF USE
N r :4
Fee ReceivedEl
N
_
Zr�r1G
O N
❑O�
Z
_ Denied _ Appeal Deadline (20 days from permit action)
txaa Form 111952-]0(0(ae,;ttd Aprit.ota

OTHER PERMITS MAY BE REQUIRED: The activity you are planning may require permits other than the CAMA
Pcrmit Numbcr minor development permit, including. but not limited to: Drinking Water Well, Septic Tank (or other sanitary waste
treatment system), Building, Electrical, Plumbing, Heating and Air Conditioning, Insulation and Energy Conservation, FIA
_ ORW Shoreline Public Trust Shoreline Othcr Certification, Sand Dune, Sediment Control. Subdivision Approval, Mobile Home Park Approval, Highway Connection, and
(For qflicial use on(I) others. Check with your Local Permit Officer for more information.
STATEMENT OF OWNERSHIP:
I, the undersigned. an applicant for a CAMA minor development permit, being either the owner of property in an AEC or a
person authorized to act as an agent for purposes of applying for a CAMA minor development permit. certify That the person
listed as landowner on this application has a significant interest in the real property described therein. This interest can he
described as: (check one)
c`f �lrrz�5 /�ie, 6A151 p uJ Y y9
lj40 �j� p06 - pO02 �an owner or record title, Title is vestal in see Deed Book
C Zi Phone / 7 pag in the ��L,0 LrJ County Registry of Deeds.
Dan owner by virtue of inheritance. Applicant is run heir to the estate of
probate was in County.
Flf other interest. such as written contract or lease, explain below or use a separate sheet & attach to this application.
NOTIFICATION OF ADJACENT PROPERTY OWNERS:
Zip Phone I furthermore certify that the following persons are owners of properties adjoining this property. 1 affirm that I have given
ACTUAL NOTICE to each of them concerning my intent to develop this property and to apply for a CAMA permit.
(Name) (Address) g Yh
name and/or directions to site. If not oceanfront, what is the name of the (I 14-,glf�'5 rp'e/o �� �7��4 O�C�/ ,�D • W/G�%���17 Td� �e "J� �t/
(2) AA11-111)NI/ oi1iB6 __ /A�S�S,rcC.ywotfo L,c/, iAc� W1/AL Ale 2BSy�
,posed construction and land disturbance.) ,�XT�t/�% �Dt' /� (q)
square feet acres
le -family ® Multi -family ❑ ) CommerciaUlndustrial ❑ Other
(Contact your local Permit QJ%ieer ijyou are toot sure which AEC applies
)OR AREA OF PROPOSED STRUCTURE:9.1_ square feet (includes
above ground level, non -conditional space elevated above ground level but
JF BUILDING FOOTPRINT AND OTHER IMPERVIOUS OR BUILT
fes the area of the roof/drip line of all buildings, driveways, covered decks,
n the applicable AEC. Attach your calculations with the project drawing.)
PERMIT: Is the project located in an area subject to a State Stonmwnter
m of Water Quality?
e surface allowed for your lot or parcel: square feet.
ACKNOWLEDGEMENTS:
I, the undersigned, acknowledge that the land owner is aware that the proposed development is planned for an area which
may be susceptible to erosion and/or flooding. I acknowledge that the Local Permit Officer has explained to me the particu-
lar hazard problems associated with this lot. This explanation was accompanied by recommendations concerning stabiliza-
tion and flooclproofing techniques.
1 furthermore certify that I am authorized to grant, and do in fact grant, permission to Division of coastal Management staff,
the Local Permit Officer and their agents 4i enter on the aforemcnlioned lands in connection with evaluating information
related to this permit application.
% This the rk day. of•,TUA/t , 20 /w
or person.nuthorized to act as his/her agent for purpose of filing a LAMA permit application
This application Includes: genend infaramtion (this.fa m), a site drmring as described on the hack of this application, the
ownership statement, the Orean Hazanl AEC Notice where necessagt a cheek for S100.00 merle ptovable to the localih:, and
any information as rum• he provided orally by the applicant. The details of the application as described by these loam -es are
inc•orl.mrated without urjaurnc•e in ate y pn»rit which mqv he issued. Deviation Jinm these details will constitute a violation of
any permit. Any person developing in an AEC without permit issubject to civil. criminal and administrative action.