67123D - Ross

!LAMA/ D DREDGE & FILL
A B
`
EN ERAL PERMIT Previous permit #
A1ew ❑Modification L omplete Reissue ❑Partial Reissue Date previous permit issued
Ized by the State of North Carolina, Department of Environment and Natural Resources (� l �,
:oastal Resources Commission in"an area of environmental concern pursuant to I SA NCAC (�� ` ► , ' (� o
((J ❑ Rul attached.
t Name11� ILbs f Project Location: Countyt1/J1?
C1 mock CMS Iyq' _ Street Address/ State Road/ Lot #(s)
���������� State�ZIP 1 �� �w` �i�L��
(--�) Ml0 E-Mai !-� Subdivision �"
ed Agent CG ✓Dk t ``� \ O V�C W44 ry a\ 'hl( 0 City 1%1 S`.�' { Gt � V ZIP � ( u
l
A,, hh
❑ CW XEW PTA O ES ❑ PTS Phone # (�� U) ' �� River Basin
ElOEA ElHHF tIH ❑ UBA ❑ N/A Adj. Wtr. Body nat
7-PWS:
yes /Cow �o PNA yes / Closest Maj. Wtr. Body Al 1,y W/
Project/ Activity
y\,6;
:k) length
itform(s)
Platform(s)
igth
nber
Riprap lengt
distance off ore
x distance Offshore
annel
iic s
ip
i
se/ Boatlift
not sure yes gn
um: n/a yes
stached: a no
0
GO�
(Scale: �� a
ig permit may be required by:_Y(�AA I V41 RT Li q ❑ See note on back regarding River Basin
_ocal Planning jurisdiction)

kC Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant: S�j]a �SS Permit #;
Date:
Ul
Describe belowthe HABITAT disturbances _fo_r the application- All values should match the_ nama,:and_unr_ts of measurement
found in your Habitat code sheet.
TOTAL Sq. Ft.
FINAL Sq. Ft.
TOTAL Feet. I FINAL feet
(Applied for.
(Anticipated 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
and/or temp .
restoration or temp impact
temp impacts)
I impact amount)
tem impacts) amount)
D
Dredge Fill Both ❑ Other
❑ [I—
��
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 ❑ Both ❑ Other ❑ I I I I
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑
Fill ❑
Both ❑
Other ❑
Dredge ❑
Fill ❑
Both Cj
Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

NCDEHR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
McCrory Braxton C. Davis John E. Skvarla,
)vemor Director Secretary
AGENT AUTHORIZATION FORM
Date: 6-21-2016
ie of Property Owner Applying for Permit
Skip Ross
er's Mailing Address:
35 Indian Meadows Lane
iarlotte. NC 28210
ie Number 704 400-1976
Name of Authorized Agent for this project:
Carolina Bluewater Construction
Agent's Mailing Address:
6934-9 Beach Dr SW
Ocean Isle Beach, NC 28469
Phone Number( 910 ) 575-7100
:ify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
id obtaining all CAMA Permits necessary to install or construct the following (activity):
Boat lift and floating dock
ny property located at 11 Moore St., Ocean Isle Beach NC
certification is valid thru (date) 8-15-2016
6P�Iperty Owner Signat Date

ADJACENT R-1 A RLA-N PROPERTY OWNER STATEMENT
(FOR A PIERIMQORING PILINGSBOATLLF IBOATHOUSE)
I hereby certify that I own property adjacent to
(Name of Property Owner)
property located at —A_ m% S�l .
(.� (Coto, BIock, Road, etc.)
on - l_,�( l.' �`i� ��'t�. , N.C.
(Waterbody) (Town and/or County)
He has described to me, as shown below, the development he is proposing at that location,
and, I have no objections to his proposal. I understand that a pier/mooring pilings/boatlift/boathouse
roust be set back a minimum distance of fifteen feet (I5`) from my area of riparian access unless
waived by me.
A. I do not 'fish to waive the setback requirement.
t I do wish to waive that setback requirement.
----------------
DESCRIPTION AND/OR DRAWr G OF PROPOSED DEVELOPMENT:
(To be filled in; by individual proposing development)
(Applicant Information) f`Ripa Tian roperty Owner Information)
!11altingAd b-ess Log ignatur e

ADJACENT RIPA#IAN PROPERTY OWNER STATEMENT
(FORA PIER/MO RING PILIIVGSBOATLIFTIBOATHOUSE)
I hereby certify that I own property adjacent to ko< S 's
(Name of Property Owner)
property located at , fflva S �
n on (Lot, Block, Road, etc.)
�/ �
tl. , N.C.
(Waterbody) (Town and/or County)
He has described to me, ass own below, the development he is proposing at that location,
and, I have no objections to his prop sal. I understand that a pier/mooring pilings/boatli#i/boathouse
must be set back a minimum distan a of fifteen feet (15') from my area of riparian access unless
waived by me.
I do not wish to wai e the setback requirement.
I do wish to waive setback requirement
DESCRIPTION AND/OR
(To be filled in
SAWING OF PROPOSED DEVELOPMENT;
individual proposing development)
(Applicant Information) --- --~ (Ri Panian periy Owner Information) --
3

CAROLI NA BLUEWATER CONSTRVCTION
Custom Beach, Mainland, and Golf Cour5e Homes
Complete Design/ Engineering / Building
6934-9 Beach Dr. 5W, Ocean We Beach, North Carolina 28469 [phone]
CANAL4
7V-H• 18'-0• 12'�• 1P-0'
6dsting Dods
to be modified to
16' x 8' w/ 8- Piles I soaiLift5
E I & 10- Piles
�I I
a
m
W
w
baelYq MHWL
FYh CINn
S20'00*M 49.79' SLlbn a alavorm
Bulkhead
Parcel M 2440JO21
Owner. Lance & Beverly Youngpuist
1CM, r ivww rj..k RA CW