62509D - Kelley

QAMA / DREDGE & FILL ✓ N9 Ex'
NERAL 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 1Z c L
Coastal Resources Commission in an area of environmental concern pursuant to I SA NCAC
j Rule3 attached.
itName i I i Project Location: County
1 (/ -} Stre t Ad ress/ State Road/ Lod #(s
State ZIP g �� 312. ��U f ht-� �+
(11XA) "7 -6 iD-) Fa>
zed Agent
d CW EW tPTA
❑ OEA HHF ❑ IH
❑ PWS: ❑
yes;% no PNA yes
31 Project/ Activity
lock)
pier(s)
length
umber
!ad/ Riprap length
vg distance offshore
oax distance offshore
channel
ubic yards
amp
use/ BoatliftT X
ounuozing
Length
ne
not sure
yes
no
igs: not sure
yes
no j
)rium: n/a
yes
no
yes
no
❑ UBA ❑ N/A
Crit.Hab. yes(1 no
Subdi ision 1
City. ' 1�1
Phone #
Adj. Wtr. Body l
Closest Maj. Wtr. Body
I,,- ZIP L`'(`1
River Basin 1..... V j' I
(Scale: t ��
Attached: yes'/',k6, =
ling permit may be required by:
- .... --1
Ok bt U UOL4-, 1-6Lk 1 (L ❑ See note on back regarding River Basin
0,\1, A 1 ..) n 6 P t'11.. , fcrll. 1 C" I� ila 1, A j ,,I " - 1

Permit #: l!! Z S uc� 0
Describe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
found in your Habitat code sheet.
TOTAL Sq. Ft.
FINAL Sq, Ft.
TOTAL Feet
FINAL Feet
(Applied for.
(Anticipated final
(Applied for.
(Anticipated final
DISTURB TYPE Disturbance total
Habitat Name
disturbance.
Disturbance
disturbance.
Choose One includes any
Excludes any
total includes
Excludes any
anticipated
I
restoration
I
any anticipated
restoration and/o
I
restoration or
and/or temp
restoration or
temp impact
temp impacts)
imoact amount)
temn imnarfcl
mmmunh
Dredge ❑ Fill ❑ Both ❑ Other
■ Complete items 1, 12, and 3. Also complete
item 4 if Restricted is desired.
• Print your name and address on the reverse
so that we can return the card to you.
2 Attach this card to the back of the maiipiece,
or on the front if space permits.
1. Article Addressed to:
A Sign
X „.
J
u�Addressee
B. Received (Printed Name) Cam_. Date of Delivery
J
D. Is delivery address different from Item 1? ❑ Ye
If YES, enter delivery address below: o
3. Se Type
D
Certified Mail
(3 Express Mail
❑ Registered
❑ Return Receipt for Merchandise
❑ Insured Mail
❑ C.O.D.
4. Restrict d '
2. Article Number a ehvery? (Extra Fee) ❑ Yes
(Transfer from service !abet) 7 010 3090 0003 7157
PS Form 3811, February2004 0881
Domestic Return Receipt
102595-02-M-1540•

WARITIME BUILDERS, INC. 12-06
1957 STONE BALLAST WAY SW
OCEAN ISLE BEACH, NC 28469-6537
2543
--7 66-19/530 NC
DATE / % �� 2210
DOLLARS
krica''I
�Z6..1
311■ iM 5 3000 i 9 61: 237000S863131,115

NCR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue James H. Gregson Dee Freeman
Governor Director Secretary
AGFNT AUTHORIZATION FORM
Date:
Naml�-p�f Property Owner Applying for Permit: Name of Authorized Agent for this project. ,( %
Ow er's Mailing Address
O
itfsbi c273/2.
Phone Number f V) nls "
Agent's Mailing Address:
A1Se!9CI4 ZL C----
q70 8 6 Z �—
Ptlong Number ( ) YZ - .�
I certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
for and obtaining all CAMA Permits necessary to install or construct the following (activity)
(my property located) at
This certification is valid thru (date) /2/ 3 �Il3
operty Owner Signature Date
/e
Z Owe 9

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORLNG PILI.NGSBOATLIFTBOATH�OUSE)
I hereby certify that I own property adjacent to � 4j �Cll e - 's
(Name of Property Owner)
property located at
/4,j i -e� -�v
(Lot, Block, Road, etc.)
on�yin C✓l�G�h� �X� v.C.
(Water�byoJdyy) (Town and/or County)
Applicant's phone #: � Mailing Addr� e o� ���� �C 2
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
must be set back a minimum distance of fifteen feet (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 not wish to waive
I do wish to waive that setback requirement.
-------------------------------------------------------------------------------------------------------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
(Information for Property Owner Applying
for Permit)
Mailing Address
U so, /Zo q
City/State/Zip 27 3 / Z
(Riparian Property Owner Information)
Sienature
Ze-c Z��eeOL
Print or Type Name

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