66638D - Shelow

�CAWIA / ❑ DREDGE & FILL
L A B
0ENERAL PERMIT Previous permit#
New ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
rized 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
_ ❑ Rules attached.
t Name �' ALov� Project Location: County '`
C-fr r.M1 Mt b�%G�-^, Street Address/ State Road/ Lot #(s)
Stag`-.— ZIP
E-Mail _ _ __ Subdivisipn
ed Agent T ( �I i p�-cam' ^ City J � �/y il�Y�n ZIP -I
❑ CWEW 'PTA ❑ ES ❑ PTS Phone # River Basin
❑ OEA ❑ HHF ❑ IH ❑ USA ❑ N/A Adj. Wtr. Body P- I W
❑ PWS:
yes / no PNA yes C:t) Closest Maj. Wtr. Body
f Project/ Activity
ck) length i'DW
itform(s)
Platform(s)
ier(s)
igth
rnber
i/ Riprap length
distance offshore
x distance offshore
um: n/a yes O
Yes
_...
,ttached: yes no T N
ig permit may be required by: �"�%GI�
focal Planning Jurisdiction)
(Scale: I I
❑ See note on back regarding River Basin rt�

NC !Division of Coastal .Mgt, Habitat lmpact' C®.n9ptlte@" Sheet
✓ �G1,�if 4G1�
pplicant:
ate:
escribe below the HABITAT disturbances for the application.
values should match the name, and units of measurement found in your Habitat code sheet.
,ll
TOTAL Sq. Ft.
for.
(Anticipated finalor.
FINAL Sq. Ft.FantiCipated
et
FINAL Feet
(Anticipated firr
DISTURB TYPE
DISTURB
(Applied
Disturbance.totai
disturbance.
Excludes any
ce
es
disturbance-
Excludes any
Name
Choose One
includes any
anticipated
restoration
.
ted
restoration and
restoration or
tem impacts
and/or temp
irnact amount
or
tem irn acts
temp impact
amount
W
Dredge ❑ Fill ❑ Both ❑ Other
5
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑. Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Applying for Permit: 0�w
Mailing address:
Phone Number: 8 j 1 — S -71 — qp q
t, , �
I certify that I have authorized I t
Age t Contractor
to act on my behalf, for the purpose of applying and obtaining all CAMA permits
necessary for the proposed development of Dro G L—
at my property located at —1 U �L� S �� Il rva o �_
in V County.
This certification is valid through
Date
v-0 SkCj'z,j
Print or Type Name
Title
/, I1/ / 1 !

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date 5 3,ol `�
Name of Property Owner Applying for Permit:
Mailing Address:
Address: /' Q,
ra,rq nsr t�� 5-1 1 '
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
,1,
install or construct (activity)
at (my property located at)
This certification is valid
Lee \QA - w *
(date) _ /Z/jl //!
s13,/a
Date

10
Name of Property Owner Applying for Permit:
Mailing address:
Phone Number
cfflW that I have authorized PPt&q
to act on my behalf, for the purpose of applying and obtainkV all cAMA permits
necessary for the proposed development of
at MY Prq).eq located at
in
0* I-blt L-A 0
County.
This certification is valid through
Date
PrR -Or 7)". NWW

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to - cvV tie_ W s
(Name f Property Owner)
property located at 1 cl`6 � S rA S �� 1l o 01
on `s' w
(Waterbody)
(Address, Lot, Block, Road, etc.)
in k- ' - 0'tJ N.C.
(City/To n and/or County)
The applicant has described to me, as shown below, the development proposed at the above location.
l/ I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must trill in description below or attach a site drawing)
' � n o2%'t'j S , tj
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set back,
minimum distance of 15' from my area of riparian access unless waived by me. (If you wish to waiv(
the setback, you must initial the appropriate blank below.)
I do wish to waive the 15' setback requirement.
r/ I do not wish to waive the 15' setback requirement.
n)
Ll : 0 C"A-L-�v L'J
Print r T e Name
(Adjacent Property O er Information)
Signature
Print or Type Name

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to —bct✓i dgnd i� 'S cS Wo w s
I (Name of Property Owner)
property located at / 1 Y8 S c.24S 0- �� LOP I
(Address, Lot, Block Road, et .)
on 1, C. . (mil , in (.S i nn� , N.C.
(Waterbody) (City/To and/or County)
The applicant has described to me, as shown below, the development proposed at the above location.
%\ I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(individual proposing development must rill in description below r attach a site drawing)
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set back s
minimum distance of 15' from my area of riparian access unless waived by me. (If you wish to waive
the setback, you must initial the appropriate blank below.)
I do wish to waive the 15' setback requirement. -
I do not wish to waive the 15' setback requirement.
n)
it i1) 4 01-7-u- Ltil
Printl ot o� Typ �Na it 1 W Loop - �C
(Adjacent Prop rty Owner Information)
Signatur
�e.vun^-
Print or Type Name
19 'Q y SaA 9;1( /'AA Qi1

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to ()NV f
's
property located at _ Jq g8 Se,o `-�1� L'ouCCI.Name of Property Owner)
on
Ww (Address, Lo ' loci Road, etc.)
(Waterbody) , in �_
N.C.
(City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above local
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,
WAIVER SECTION
I understand that a pier, dock, mooring
minimum distance of 15' from my area of riparian accessunlesswaived by me. ift, or I(If mout wish t wai
the setback, you must initial the appropriate blank below.) y to wai
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
erty O er Information)
(Adjacent Property Owne Information)
afore _
V �� SLOL.i Signature
Print T M Te • be'L
6 � � �� Print or Type Name
A A

AMCENT ' ANT UPARtAN PROPERTY QMFt ST11TFtdt cur
Per* that l own property adjacent to
Voirty bmw at fi SLd, hex, R of Property owner)
tru (Addres ,
tWaterbod
The applicant has deWAbed to me, as shown below, the development Proposed atthe above; M
—=-_ i haveno 0*cbiw� to this proposal.
------- l have OtOft tf to this proposal.
DESCR17g (A N 10p;1)R DRAVANG OF PROPOSED DEVELOPMENT
(1rtd6ftrl+dua/ pro poslrt� drwehtp►a�t etusi fiV 3tt desc
dpftn below or atiach a site drawin c
ta'tdenstand that a Pier.- �tA1VER l3Et`71ttN
P' deck moorir pilmgs, breakwater, boathouse, lift, or groin must be sat bac
the Setba distance of .*T from my area of riparian access unless waived by me. (If you wish o ws
the setback, you must initial the appropriate blank below.)
I do wish to waive the 15, Setback requirement.
I do not wish to waive the 13' se#ttagc requirement.
airs req
per tnfonnat) (Adjacent Property O
P Y wn4w ltrto��
n
Pnnaret or Typa T .
2�l �� n r)
L�+ati•yae�,Psi or T}rpe Name

From: David Shelow [e-mail] B
Bubject: Fwd: Drawing
Date: June 22, 2016 at 4:11 PM
To: [e-mail]
Ai Karen could you also sign and date the drawing and tape both the forms and the drawing on the inside of our screen door. Trip will come b
and pick them up.
"hanks,
)ave
--------- Forwarded message ----------
=rom: <ripQP2i2210mgrine.com>
)ate: Sat, Jun 18, 2016 at 9:57 PM
subject: Drawing
o: David Shelow rr cangdavga36C�amail com>
)ave,
-lere is the drawing. When I get the signed form from Mitch back, I'll go get the permit. It
night be a good idea to get Mitch to initial and date the new drawing.
-hanks,
'rip
Trip Pippin
Pippin Marine Construction, LLC
►10-270-1290 - Office/Fax
110-471-2034 - Mobile
�ww.2ijZ- m rine&om
ripCa pijZRinmarine.com
cazlc . la4u [
sae' 1
I
i

M ��
� ��_
l �
�' O�
��I_
.. ., .