67293D - Raby

ICAMA / F1tDREDGE & FILL r l/ ! %1 q/l b
aA ENERL PERMIT ` ///
INew ❑Modification ❑Complete Reissue ❑Partial Reissue
•ized by the State of North Carolina, Department of Environment and Natural Resources
:oastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
t Name 6ktl \ '
State
NY
-Mail
ed Agent
❑ CW XEW PTA *S ❑ PTS
❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS:
yes (no), PNA
Project/ Activity _
:k) length_
itform(s)
Platform(s)
igth
nber
i/ Riprap length
distance offshore
x distance offshore
cannel
sic yards
ip
se/ Boatlift
x
Length
not sure yes
ium: n/a yes
yes
\ttached: yes
Project Location
B
Previous permit #
Date previous permit issued
21101
BYatttached.
County v W'
Street Address/ State Road/ Lot #(s)
Subdi 'sion
City ZIP
Phone # ( ) River Bin
Adj. Wtr. Body �� l at r
Closest Maj. Wtr. Body v
(Scale:
ig permit may be required by: 1 1)' Vak UA ULL - ❑ See note on back regarding River Basin n
Local Planning jurisdiction) � t N-it n,_. e I i . f. I :,

Applicant: Alt)
Date: hDescribe below eB AT
NC Division of Coastal Mgt. Habitat Impact Comp
td)"11 _
1
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.
(Anti
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
distL
Excl
Habitat Name
Choose One
includes any
anticipated
Excludes any
restoration
total includes
any anticipated
rest(
restoration or
and/or temp
restoration or
teml
ternimpacts)
impact amount)
tern im acts
amo
P�
Dredge ❑ Fill* Both ❑ Other ❑
1��
'
c
Dredge ❑ Fill ❑ Both ❑ Other ❑
V
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both 0 Other ❑

'ayment Proccessing Confirmation
)ate Received 11/9/2016
:heck From (Name) Allied Marine Contractors LLC
Vame of Permit Holder Michael Raby
✓endor First Citizens Bank
*heck Number 5017
#heck amount $600.00
Multiple Permits Yes
Major/Minor
Permit Number/Comments GP 67293D
Receipt or Refund/Reallocated TM/3451D

CCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue James H. Gregson Dee ecreta
Governor
Director Screta
AGENT AUTHORIZATION FORM
Date:
lame of Property Own plying for Permit: Name of ,Ath orize/d Agent A'l�t�( fectiti
M► �
)wner's Mailing Address:
phone Number (0) 1- `35 2
Agent's Mailing Address:
Phone Number ( V ) o�3c) " c2,5(2—
certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
or and obtaining all CAMA Permits necessary to i 7tall or construct the following (activity):
,my property located) at IQS 2L" , -
This certification is valid thru (date)
`-Z— 6
Date
r)wnPr Signature

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to �0. CJ 's
(Name of Property O ner)
property located at LA I o 1D Z % 2-
(Lot, Block, Road, et .)
on S an4 , in Da K -T�5l C6-\l , N.C.
(Waterbody) (Town and/or County)
Applicant's phone #:�b9'27�v- Mailing Address: 710 1 twC-G<
vnS kV,- ,
He has described to me, as shown below, the development he is proposing at that location, and, I
have no objections to hi4prposal.
�y ">
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by property owner proposing development)
LA I0
-------------------------------------------------------------------------------------------------------------------
(Information for Property Owner Applying (Riparian Property Owner Information)
for Permit)
��0 1le

CERTIFIED MAIL — RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to
)erty located at
CIAI
oj�'
(Name of Propeity Owner)
(Lot, Block, Road,1 c.)
in V�j��rK , N.C.
(Waterbody) (Town and/or County)
licant's phone #: Mailing Address:
CA gg
he has described to me as §hown blow tfie L)elopment he/she is proposing at that location,
have no objections to the proposal.
•-----------------------------------------------------------------------------------------------------------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(Individual proposing development must fill in description below or attach a site drawing)
q�G,
have objections to what is being proposed, you must notify the Division of Coastal Management (DCM) in writin
110 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive Eat Wilmington, NC
representatives can also be contacted at [phone].
No response is considered the same as no obiection if you have been notified by Certified Mail
.)erty Owner Information)
totr .r�
ture
�45
or Type Name/ /�
A, C�aP/1 �. ,
(Ri r' n Property Owner Information)
Signature
4,
Print or Type Name