69309D - Scotti

AMA / F'' DREDGE do FILL Pd ? 69309 A B C
IG�-'EtFAL PERMIT Previous permit #
r
i,ication Reissue 'Partial Reissue Date previous permit issued
��1glete/
:horized by the to No r artment of Environment and Natural Resources I 1 ��
ie Coastal Resour s Commission in an ea of e� 'ronmental concern pursuant to 15A NCAC v El R attached.
ant Name
/' Project Location: County
Ms © M�1 fiG �i% Street Address/ State Ro / of ;)
`/✓ Gi��1 _ State ZIP
e # c �//T�71�9 E-Mail Subdivision_
)rized Agent � T41L r5<---- ,-- City �' �� ZIP
i 1CW hEW y�TA ❑ES -IPTS Phone # ( River Basin
I ed ❑ OEA ❑ HHF ErIH ❑ UBA ❑ WA
s): Adj. Wtr. Body- &&//i'1 nat m
❑ Pw5
/%Z�) no PNA A/ no Closest Maj. Wtr. Body-�
of Project/ Activity
¢ing Platform(
;er pier(s)____), —/
,in length
max
in, cha
cubic yards
it ramp --
ich Bulldo7ing
ier
xeline Length _1_f --- fo
v: not sure yes
watorium: n/a yes
xos: yeses
liver Attached! /yes,
YAW 3 *3( =
p, -eA_
ow 1� ��2f [I!*•
14
CC"it;4T,4G
G�F�1 MJUS
he.A.1
G+:e f
Pt 4 tif4f 7 ' // 7
-/,w
Mi�IW O�C 541OU
See note on back regarding River Basin rn
>uilding permit may be required by: /v
1— 1 ­1 Phnnino luri-Airtinnl

CAMA / ❑ DREDGE & FILL 10 /� S r A B
iEIV=1AAL PERMIT Previous permit #
New Modifi�atio C}�o rplete Reissue ❑Partial Reissue Date previous permit issued
ized by the Stat@ bf No aCrlinalpartment of Environment and Natural Resources d (Z d
oastal Resources Commission in an area of environmental concern pursuant to 15A NC ❑ Rules attached.
Name t` Project Location: County jryj�y u vvf Street Address/ State Ro /,Lot # s)
G�✓ /9 f % f%/�� rT
State ZIP
S/3-'7z�9 E-Mail Subdivision
ed Agent City
n !� �� ZIP
❑ CW to EW ALP, ❑ ES ❑ PTS Phone # River Basin `
❑ OEA �❑ HHF ❑ IH
❑ PWS:
y no PNA es no
❑ USA ❑ N/A Adj. Wtr. Body ✓✓� �� �� nat r
Closest Maj. Wtr. Body 'd
IV7 6
ling permit may be required by:
❑ See note on back regarding River Basin

Name of Property Owner Requesting Permit:
Mailing Address:
16V
Phone Number:
U
Email Address:
l�£.rs' Spa Tj-
C ,P
I certify that I have authorized
Agent /Contractor
to act on my behalf, for the purpose of applying for and obtainingall
necessary for the following proposed dCAMA permits
development:
131 my property located at
►n.,,s�County.
l furthermore certify that I am authorized to rant and Division of Coastal Management staff_ tho / o gi Pormit O a, fact grant permisslonlu reo
nrr thu nrorer»cnflo���c! lands in connection with evaluating information related to this
Permit application.
Property Owner Information:
-,Z� -�
Signature
C�y.r S s m
Print or I ype Name
O`L,fY2�"L
Title

(Property Owner Information)
.ti'i �ncrr trrc•
Pr tit or Type Name
ri0 !J SL4 4Mr�t
Mailing Address
�L A f came 4
-r-
r-,�,
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to Cl/RN .Sc o
me of Property Owner)
property located at O r`'0 Vz 61 F �!t
(Address, Lot, Block, Road, etc.) N.0
5o U N0 . in /1!O �' 'T�1 '%C�f'c a �> �'�i9 C N
on .S'%U 1N (Waterbody) (CitylTown and/or County)
The applicant has described to me, as shown below, the development proposed at the above
loc tion
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)
Q 00 C/fc 4 f e9T!uA1s1
DO Ct 4ZMbvj' u.nv
W -"'N -rN-r- O 1QZ CG -r "V A
.A/ v7- %Z)
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. (If you wish to waive the setback, you must initial the appropriate blank below )
6<p _ 1 do wish to waive the 15' setback requirement
I do not wish to waive the 15' setback requirement
(Adjacent Prop rty wner Information)
r�Re oR K
Pnnt or Type tV +ne
lnSo1014 Mathqg Addre / 4, ,tJL 2 pI6
City/State��p Jfl,

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
to CH2 r adjacent ` Sc 0TTs s
i hereby certify that I own property ad J (Name of Property Owner)
property located at % 6 4 D G 6 vrr «f d e '/ Road, etc.)
(Address, Lot, Block,N C
�Tu 6�ChN
on -S � U m � S U � �o ' in LV R (Waterbody) (CitylTown and/or County)
The applicant has described to me, as shown below. the development proposed at the above
locati
l have no objection to this proposal.
V7-
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)
Doe& 'olinfNSrGNJ wrcc AJ-i+J!rr'^� co1vSrS7d!f-7-
W .r - P A r 6 rev AD Zi., r o's/ /t/O i ?v .
Fxcl�-o d o x k0 ;.
WAIVER SECTION
I understand that a pier. dock mooring pilings, boat ramp breakwate1. boathouse, lift, or gran
must be set back a minimum distance of 15' from my area of riparianunless 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
(Adjacent Property Owner Information)
(Property Owner Information) ,
Signature Signatur
CyRrS SCO 7 T.t Print or Type Name
Print or Type Named
S6 0 V S u /r, F/Z C R k l v f;,
M7&nq Address �L �9,-
Mailing Address 3 0 5��� 1-
C�LFn. ACCF�yr ✓A �30

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