69269D - Williams

JCAMA / ❑ DREDGE & FILL
GENERAL PERMIT
Pew ❑Modification ❑Complete Reissue
it-, i I -r'ISW'
El Partial Reissue
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Previous permit # t
Date previous permit issued_Sr(—'
prized by the State of North Carolina, Department of Environment and Natural Resources / , � 4 '% 6
Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC ' !i��
,/�,� _ , ,, / p, �' ❑ u s attached.
nt Name ' r' ( t V v � U I P V v�S Project Location: County yi (',
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ling permit may be required by:
❑ See note on back regarding River Basin

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit:
Mailing Address: bU'J i�G� Y1(.L, ('��` �QG�';t�Y MO-Vi O—,
0 C&d 5 lac -�e �r INC 2 fs / U o
Phone Number: 9)q • Laa'Q• qt�,
Email Address: t`(1i l' e, t i �} i �im.� h�a Can
I certify that I have authorized `f� E006t -- EWA+ MOdAe,
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: Mo\j P PXf;'4i G t-F+',to
not iYtSidP 5►i,p uabq ntA4) aS" iZcx y),j polf g
at my property located at 4 Yk yG MOria-
in _County.
1 furthermore certify that 1 am authorized to grant, and do in fact grant permission to
Division of Coastal Management staff, the Local Permit Officer and their agents to enter
on the aforementioned lands in connection with evaluating information related to this
permit application.
Property Owner Infor ation:
Signature
Mt�1�e. ���jtt�ams
Print or Type Name
l-h�tvLP � .tz
Title
Date

o�-
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to �rnI FCI w i (! j A,(Y1 s 's
property located at
?03 Marina. C-t trome os Property vwiior)
on ��1-, '^^,�, l (Address, ot, Block, Ro etc.)
I 7 t�1 C.i , in �Ia PC1 ai -, � X yt l{ / 0050(A) , N.C.
(aterbody) (Cityfrown a/or County)
The applicant has described to me, as shown below, the development proposed at the above
location,.
raz.l� I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(in dlvldua1, proposing developmenf must f ll'iri'd befow or attach a site drawing)
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 accoss unless waived by
me. (If you wish to waive the setback, you must initial the appropriate blank below.)
Date
I do wish to waive the 15' setback requirement
I do not wish to waive the 15' setback requirement.
(Adjacent Property Owner Information)
Slrature• _
c,.`1I;.- A t-.rosel.�t,se
Print or Type Name
AdADVAtx-
ddret
5chwubCRylSlataq*
,/n 3� t-3,7z
• (nm Telephon��eNumber/erna# di as
i
Dare*
'Valid for one calendar yoar after signature* Aw& 2014)

I hereby certify that I own property adjacent to __fY1 i K4z" M MGM S
property located at :303 Mar roan C-f (?mama oz Property wwa, r)
on �<:�`�3a M �� (Addro'rs, ot, Block, Road, etc�
L U0 t� , N.C.
( atorbody) (Cltyrrown a for County)
The applicant has described to me, as shown below, the development proposed -,tt the abovo
location.
I have no objection to this proposal.
I have objections to this proposal.
..DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(l�itlly/dtia jvropo Jng:alevQldplti Ant'rtius't i�J1L`( "i1Q$crlp�loir,tie/oWos attach as
ite dr wJng)
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, i'ttt, 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.) )
I do wish to waive the 15' setback requirement.
3 I do not wish to waive the 15' setback requirement.
(Prope nor
a`
Si re
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Pant or Type
/�N'rA.me -{jam
Tel, hone Number/dma11 address
(Adi2cent Property Owner Information)
` "I J ETA;, N 14 K-c clit-K
Print or Type Name �
�o s f� /�'� AA T
Mallln Address / G
h
c;tyjsfateffip
�chl t� I / o - 3 ti? - u (t 3
` (°m Tetephone Number/ -email address
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