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ADJACENT RIPARIAN PROPERTY OWNERp STATEMENT
'I hereby certify that I own property adjacent to MQ. • tit„•' Sib f- 's
property located at 3,35 As-rEe i f f:x-ame VriMPrtragg
C
(Address, Lot, Block, Road etc.) �-Jo
on 1 tJt J 't V CK. , in P M) t41/41 p0 e _ , N.C.
(Waterbody) (City/Town andlor County)
The applicant has described to me, as shown below, the development proposed at the above location.
17 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, breakwater, boathouse, lift, or groin must be set back a
minim distance of 15' from my area of riparian access unless waived by me. (If you wish to waive
the et 'a•k, you must initial the appropriate blank below.)
A 1 do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
k (Property Owner In ormation) i< (A ' cent roperty ner information) k
si S OSPn*l tg q s��,� rl d c) ' I D /le-
Print or Tyne lS•ame Print or Type Nam
361 �'C�(rr._ ikerC �j +r✓� �`
MaAc„j� Infr,,t n c I,43 Maili g Ad� C , `3
City/State/Zip City/St ipz, - 1/1
g V
Telep one umber _ci Telephone Number
N'It; 2°
Date I Date
29 I 2 G 2-tom • (Revised 6/18/2012)

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner. .
C.
K, N' f &.
Address of Property: 383 Pk-.ST - t AS( I v C, 2 A 3
(Lot or Street#, Street or Road, City&County)
Agent's Name#:____________idlih_ Mailing Address:
Agent's phone#:
44* , I hereby certify that I own property adjacent to the above referenced property. The individual
applying for this permit has described to me as shown on the attached drawing_the development
they are proposing. A description or drawing, with dimensions, must be provided with this letter.
I have no objections to this proposal. I have objections to this proposal.
If you have objections to what is being proposed,you must notify the Division of Coastal Management(DCM)in
writing within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive Ext.,
Wilmington, NC, 28405-3845. DCM representatives can also be contacted at(910) 796-7215. No response is
considered the same as no objection if you have been notified by Certified Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, 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.)
IJdo wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner I ormation) * (Adjacent Property Owner Information) C
Signature Signature
(- 8 ../
Print or Type Name Print or Type Name
361 Pit\-- .,
Mailing Address Mailing Address
+VCIAPSTgAID 2-4FSIEL4
City/State/Zip City/State/Zip
Telephone Number Telephone Number
Za l°tCA CA 2-2-7-
Date Date
1 1 1 O 20 , Revised 6118/2012

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: AS S�f\--t -V 84-01.
Mailing Address: 36 f ..4 -P C
-I' tPS't 9-84Lt-
Phone Number: Z0 J 4— \9 9 2 2
Email Address: 1 i Pr1 cxt Tee .
I certify that I have authorized NI`pc
Agent/Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
at my property located at
in County.
I furthermore certify that I 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 Information:
Sign.
5 L)5'Pc ) J 8 P—RY/
Print or Type Name
MCS -
Title
9 , 2 `c+ , 2t1O
Date
This certification is valid through / /

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•LAMA
/ _IDREDGE & FILL No. 73585 A B C D�
GENERAL PERMIT Previous permit#�,-C`j":.—►-,; (,J
��-%'0New ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued -71 3.2T•14
As authorized by the State of North Carolina,Department of Environmental Quality //ll /
COand the Coastal Resources Commission-in an area of en ironmental concern pursuant to I 5A NCAC (J� r .
/ ❑Rulespttached.
Applicant Name)&54v I �' i , A. u °` / h141.t4Project Location: County I'VA ci.(Ach
Address c.i3C) 0 A or* 1...--1V . Street Address/State Road/Lot#(
CitY\ L/I-I N5-T o N State Ft ziP22 341 ," 1 Ut //
Phone#,) I/01--77-74- E-Mail Subdivision 4 ! ii-q A 4-�` u z
Authorized Agent "I / - City t, '4 ZIP �%
❑CW [ W [ A ❑ES ❑PTS Phone# ( ''� River Basin h id
Affected
AEC(s)a, CIOEA ❑HHF ❑IH UBA ❑N/A Adj.Wtr. Body / L'f4./'i" i ' AO/man /unkn)
❑ PWS:
ORW: yes no PNA 0, no Closest Maj.Wtr. Body ' tt- 0 e)'P
`'�
Type of Project/Activity f t- -� ,.1-- \ ON,— 'k
I I r
cale:
Pier(dock)length l' a�.•
Fixed Platform(s) ! 1
- -.__-.
Floating Platform(s) ( i
Finger pier ) r
Groin len Ii
numb I
Bulkhead/Rip p lengt. I 'Ni ��
avg distanne: shore I j ( I i
max dis c_ offshore a'°11
Basin,ch. nel
"-tri" - N
NI
'
cubic yar 1 1 I
� I
Boat ram. S[h f0.. t/ �I
Boathouse/Boatlift i f '�
n
+ '
Beach Bulldozing I i I '
,,
Other k
4 ....,
� I r,/_
` !
Shoreline Length fir_ !�q 111 . ,- _ ,/ -lc' -.LXI /
�-
SAV: not sure yes _- •' I ! . 1 i • gIlli
I I',/t d L }�.
Moratorium: n/a yes ,41110 1111.11111111111111■ l ■■.®
Photos: yes _' 1
® ����
nr
Waiver Attached: C�� 'n Ne\/ f 1 I
A building permit may be required by: / `e4441 . I See note on back regarding River Basin rules.
(Note Local Planning Jurisdiction)
Notes/Special Conditions
+%G it ra sj.tit
_ 46 5A:ix_ ,o1---0-or Aop it can - . eed :me Pe er's Printed Name
ign.hour e**P ease r .d compliance statement on ba _ permit Sig re G ,
Application Fee(s) Check# Issuing Date Expiration Date