66135D - Kozak

fCAMA / ❑ DREDGE & FILL
3ENERAL PERMIT Previous permit# A B
New ❑Modification El Complete Reissue El Partial Reissue Date previous permit issued
rized by the State of North Carolina, Department of Environment and Natural Resources tt '
.oastal Resources Commission in an area of environmental concern pursuant to 15A NCAC f"t • I
` Rules attached.
t Name 1161 Project Location: County0111`ylh(.-b—
:;'`` ' T/ [�--O it Street Address/ State Road/ Lot #(s)
tt. { State ZIP 1:1L .t utiA VG
' )LJ E-Mail Subdivision ILA
edAgentJ- �G 4 � City ��)�r'J{�tLt.% ZIP �.�Mto
❑ CW 'kf )OTA ❑ ES ❑ PTS Phone # L (�) River Basin W'
❑ OEA /❑ HHF ❑ IH ❑ URA ❑ N/A
El PwS. Adj. Wtr. Body t. �vk� (na
Closest Maj. Wtr. Body
yes i no PNA yes G no
'Project/Activity I )n. A,A V (:t ML.J rv- ur3t,
y
(Scale:
ck) length " I �-'
atform(s)
Platform(s k
ier(s)Z1 �Y
l "
ngth
tuber
J/ Riprap length
distance offshore
x distance offshore
cannel
)ic yards
1p
se/ Boatlift
AIdozin
!OA x ,
Length
not sure vest no
ium: n/a
\ttached: ( yes
ig permit may be required by: 1--) See note on back regarding River Basin rt
Local Planning Jurisdictiac

10/20/2015
Antinori Construction Inc
Roger Lewis
B of A
10/20/2015
Custom Island Homes by Ken Kiser LLC
Ken Kiser
CresCom an
10/20/2015
Custom Island Homes by Ken Kiser LLC
Ken Kiser
CresCom Bank
10/20/2015
Custom Island Homes by Ke_n Kiser LLC
Ken Kiser
Bank
10/20/2015
Custom Island Homes by Ken Kiser LLC
_
Ken Kiser
_1CresCom
CresCom Bank
10/21 /2015
Money Order for Brandon Grimes
Scott Pindell
Wells Fargo Bank
10/21/2015
Money Order for Brandon Grimes
Scott Pindell
Wells Fargo Bank
10/21/2015
Clements Marine Construction Inc
Vern Hawkins
First Citizens Bank
10/21/2015
'Ocean's Edge Ventures LLC
Margaret Ann Maida, LT
BB &T
101 0/22/25
TRCK
same
BB &T
10/22/2015
Town of North Topsail Beach
same
First Citizens Bank
10/22/2015
Allied Marine Contractors LLC
Beck Olb ch
B of A
10123/20151
Grice Construction
Barry Wishon
&T
10/23/2015
Holden Docks and Bulkheads
—d—BB
John Kozak
CresCom Bank
L v
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c
_ I 3
U 1- -1 o O
3890 $400.00 GP 64767D + GPSE
3844' $400.00 major fee, 7404 E. E
3845' $400.00 major fee, 7406 E. B
3846 $400.00 major fee, 7408 E. E
3847 $400.00 major fee, 7410 E. B
59183420318 _ $400.00 GP 66167D (a�$600
59183420329� $200.00 GP 66167D @$600
3933 $250.00,major fee, 202 King:
6777 $600.00 GP 66131D
1529 $100.00 renewal fee, MP 67-1
40151 $400.00 GP 66110D
7923 $400.00 GP 64 772D
10616 $400.00. GP 66132D
2286 00.00 GP 66135D

-NC Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant: �� "—L
Date:
1
Permit #: l � 1-3c,-
Describe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
found in your Habitat code sheet
Habitat Name
DISTURB TYPE
Choose One
TOTAL Sq. Ft.
(Applied for.
Disturbance total
includes any
anticipated
restoration or
temp impacts)
FINAL Sq. Ft.
(Anticipated final
disturbance.
Excludes any
restoration
and/or temp
impact amount
TOTAL Feet[disturbance.
(Applied for.
Disturbance
total includes
any anticipated
restoration or
tem impacts)
NAL feet
nticipated fina
cludes any
storation and/c
temp impact
amount)
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 ❑
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 ❑

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ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
1 hereby certify that I own property adjacent to `. s
(Name of Property Owner)
property located at Ty�7Gr !%��
(Address, Lot, BIQcJc, Roadfgtc.)�
on /i1AA hMf e 6qi� . � in 471 4 e" exY <— N.C.
(Waterbody) (City/Town 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 fill in description below 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 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.
(Property Owner Inform tion)
i ature
Print or Type Name
(Adjacent Property Owner Information)
r//�; P, 0 Z
Signature*
Print or Type Name
Mailing Address
City/State/Zip
!go � - ? / V - 38�'4f
Mailing Address
City/StatelZip
9/v 7-34 - 3GX7

?1.07/2004 19:20 9108429806 GREG HOLDEN
DIVISIpN OF COASTAL NANAGEMfhU
ADJACENT BMAIM PROPERTY QMM NOTI,1PICAT1Q)9/WhiZiZF= FORH
Name of Individual Applying For Permit: _4X,0A7
Address -of Property: /04I-!S Dr-,
PAGE 01
(Lot -or Street Street or Road, City & County)
I hereby certify that I own- property adjacant to the above-
rafer,anced property. The individual applying for this permit has
described to me as shown on the attached drawing the davelop mnt
they are proposing. A description or drawing, with dimensions,
should be provided with this l*ttQr.
I have no objections to this proposal_
I understand that a pie~, dock, mooring pilings, breakwater, boat
house, lint _ rust be set back a minimua distance of 15'
from my area of riparian access unless waived by gun. (If you wish
to naive the setback, you MU" initial the appropriate blank
below.)
I ,do fetish to waive the 15 t setback requiroment-
I dg not Wish to waive the 15'setback requir*ment.
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