79004_John Kosch_20210113

1 _ _,..
0 XCAMA/ i_=I DREDGE & FILL N9 79004 ® C D
GENERAL PERMIT Previous permit# A/ A.
)17—'' KNew [iModification ]Complete Reissue [-Partial Reissue Date previous permit issued 1'�
As authorized by the State of North Carolina,Department of Environmental Quality N J
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC 04 1, 1 2C X .
` � Rules attached.
Applicant Name S-O Y�'v-N \<OSGI'] Project Location: County /;;1((le l)
Address (p b I&
..�� _-_,,�e�-Fe('St,17 �\\J .. Street Address/State Road/Lot#(s)
City_ f eC)Gr;CAC StatefYMZIP a 1 I O 3 s B —..Al b e►r ar l2 Sl I s 2'K-+
Phone#(:30V)11'2-_IOZ1 E-Mail rA rOetetk roti.4e,M Subdivision 1 t Ir(e 5I1aeC
Authorized Agent V*2L mi ,2,_ -_/ pin_ /4natntsp,12.CityLAYM.b 1 A ZIP
Affected LlCW IkEW TA [3ES ❑PTS Phone# (3e,I )11Z2 - 2-1' River Basin
AEC s : ElOEA ElHHF CIIH I UBA ❑N/A Adj. Q 1 _ re/man/man (unkn)
E PWS: Wtr. Bod f7�115 a\/
ORW: yes <3 PNA yes / no
Closest Maj.Wtr. Body_ C_229r/ SoHyq 1
Type'of Project/Activity App�iumi pro ,r y - a in S-1-.1/ a (,'X pitr w/a /tic IL' p/44 rr+�t w, cma jb ii/ 9X 1 Z' Aria- p144-c 4 47)� a 9'X/Z' A &- Pier + rCpo:;r eXtsl►n5 (Scale: 1 it- 3 c9" )
Pier(dock)length If ler0-; '-{r'
2 I 1 . if 1 i � ,Fixed Platform(s) XIt � Z 1
t I
",— u Si 1�' Y I - L}}
,
:
t- _ ,._
Floating Platform(s) _� l tt r- -tj I -4- ,
Finger pier(s) 4' x I x' s t`cmil
i
Groin length -� N number \ ;
. i ( . kh V / I f
Bulkhead/Riprap length t ' a I 1 _ i
avg distance offshore i
, _ . ;_.� _ .. ;v - t . -I_ L
max distance offshore I
I rA J i
Basin,channel ;._ 1._�_.__'_. I I ;-' ? y/�� -� J`�y*rI v'� ._
1 ___ ___ _--_ f t yr.�f'/ t _1 i - ,..,_,,. ....`—.`—.. ,_.__..— .-,...
cubicyards ; [!!u'._ _ w.
;........__ r i f
Boat ramp i I f- I L1-1
I '
i ( -- - � — ;--1. NA • i
Boathouse/Boatlift ` i i I - r_ _.,- -
__
i ( fI b� ,fir r f,
Beach Bulldozing L j_ _ l `. T ._t} .-. i t�t'G- I i - i
Other i i II i t e —
I # r —{�ar I i 1 1
1
Shoreline Length 11g �1 �'�R.' 2 —
SAV: not sure yes no �10 rt it h j h-�l h� I 1
Moratorium: yes ®; f� �oI,1
n/a 0" ',, pits' 1 "OSC.� fre p , i 4st7..
ya�i c
Photos: yes no i i , � I i- 1 Y. . I 1
I J
Waiver Attached: yes noV' .. _..-. _ '�.? , ....._ � 1 _.. ' � �
A building permit may be required by: �f('L 1) (..ctiol4 . See note on back regarding River Basin rules.
(Note Local Planning Jurisdiction /�
Notes/Special Conditions L p i- l j mG I L I k\QI il[0 / i,1, f r/' "o p Y)D* it' Ck<<C U 10 WaT'Pr'+..be
Dan Andronowitz 46/1 le y 6 re-1,74
Agent or Ap 'cant Printed Name
Pe it0 i r s Printed Name
Signature **Please read compliance statement on back of permit Signature t_.
__1.9: 1P/I-Jer_____
Ch 1 �
Z�t3. . vq.1- 3_�- fan - 2-0L1 -- i 3 - my- to z i
Application Fee(s) Check# Issuing Date Expiration Date

OF );CAMA / DREDGE & FILL r� (0'-6 IC? N9 79004 ® C D
GENERAL PERMIT Previous permit# /l/ A-
�� Datepreviouspermit isueed l4-
�New OModification ❑Complete Reissue ❑Partial Reissue NI
As authorized by the State of North Carolina,Department of Environmental Quality
and the Coastal Resources Commission in an area of environmental concern pursuant to I SA NCAC Oi-N, I Zt O
��>/' Rules attached.
Applicant Name �O�'Y` 066 h ` Project Location: County v-((tell
Address ,101(o 5e�-F er Sc ) 1`V 0- Street Address/State Road/Lot#(s)
City f e&x;C. State Tyi17ZIP a 11 O 3 $s N' 1 J errzar le S' 1e3 2'SC+
Phone#(3D1 ) 112' 30i3- E-Mail Taty @l /aariftYroo)•to ,MY/ Subdivision 111be tirar(C ,Short,!
Authorized Agent T2 t 5 1 j441kr ectt S / , n 4ridior JZ.city (l t4yyl b i a ZIP a1 CPS
Affected ❑CW NI EW XPTA ❑ES ❑PTS Phone# (3&I )412, -1.02-7' River Basin 7 c.14'(gv�
AEC(s): ❑OEA ❑HHF ❑IH ❑USA ❑N/A Adj.Wtr. Body Bu\15 )ot.\r na /man /unkn)
❑PWS:
ORW: yes no PNA yes / no Closest Maj.Wtr. Body )1 I bernmr/c 5Cay/1 —
Type of Project/Activity j�p/ica pro� 7'Scj ;n s4A11 a (o'X �per w4 a /.2z IL' p/4 frcD w du;SA qif
atWlIc(w/ VX/)�Z' /ewo- pir v-i" Q,,ee a V i;/Z' Ate- picr ,i rrpr:ir etisitn1 (Scale: I ii- 30' )
Pier(dock)length ID i (pt)/ ..-{r..►e
Fixed Platform(s)12 X 114 T X 1'2' ` f2 tAl"S y l j : : '—
Floating Platform(s) -- F�
Finger pier(s) 4• X 2.. J__ _ ; i T.._.._
Groin length
number 1 Y \1, ± `
Bulkhead/Riprap length C -- J.._ —_.__ Mg
M\Yi -- i
ar,
avg distance offshore \�'(�\► { , � . •
max distance offshore
Basin,channel
1 : 1 i - tv i., k tft,' _ __________—
cubic yards j I I i I
f
Boat ramp I ii\
...
Boathouse/Boatlift — — 4._ .�Q rs �
Beach Bulldozing -- 56 iQ-Y'fy' t
N i3 • �� -
Other 4�� I 0 , -, -
i ;-- , y -,-.41,-,p , .t. ,,,,i,i,-,• .,.LA -i-, -,`' ' , r , I
Shoreline Length I I g yhL_ — p 0 vi•' / .st .+:,T.,,,CT_i r<c,
'4 ytvl-, t,-at 3
SAV: not sure yes no i •d
.
Moratorium: n/a yes ® �V Ko$c,S.. PRo t' I 1)/4
Photos: yes no 1 �.
Waiver Attached: yes no --- - . ,
--ri
A building permit may be required by: lirC 0 (..0 444 See note on back regarding River Basin rules.
(Note Local Planning Jurisdiction) 1 \ ( -
Notes/Special Conditions 2.,6t 13 J' ai 4 1`d)h[O Ja' fu R'prq p no tee 10 ey Wc4 An..
Agent or Applicant Printed Name Pe it i es Printed Nam
Signature "Please read compliance statement on back of permit** Signature
Ch K ,2410. 3 e.;.}1- - / 3 - -Earl - 2011 — J 3 - may— Zn2)
Application Fee(s) Check# Issuing Date Expiration Date

Statement of Compliance and Consistency
This permit is subject to compliance with this application, site drawing and attached general and specific conditions. Any
violation of these terms may subject the permittee to a fine or criminal or civil action; and may cause the permit to become
null and void.
This permit must be on the project site and accessible to the permit officer when the project is inspected for compliance. The
applicant certifies by signing this permit that I)prior to undertaking any activities authorized by this permit,the applicant will
confer with appropriate local authorities to confirm that this project is consistent with the local land use plan and all local
ordinances, and 2) a written statement or certified mail return receipt has been obtained from the adjacent riparian
landowner(s).
The State of North Carolina and the Division of Coastal Management, in issuing this permit under the best available
information and belief,certify that this project is consistent with the North Carolina Coastal Management Program.
River Basin Rules Applicable To Your Project:
Tar-Pamlico River Basin Buffer Rules Other:
Neuse River Basin Buffer Rules
If indicated on front of permit,your project is subject to the Environmental Management Commission's Buffer Rules for the
River Basin checked above due to its location within that River Basin. These buffer rules are enforced by the NC Division of
Water Resources. Contact the Division of Water Resources at the Washington Regional Office (252-946-648I) or the
Wilmington Regional Office(9 I 0-796-72 15)for more information on how to comply with these buffer rules.
Division of Coastal Management Offices
Morehead City Headquarters Washington District
400 Commerce Ave 943 Washington Square Mall
Morehead City, NC 28557 Washington, NC 27889
252-808-2808/ I-888-4RCOAST 252-946-6481
Fax: [phone] Fax: [phone]
(Serves:Carteret,Craven,Onslow- (Serves: Beaufort, Bertie, Hertford, Hyde,
North of New River Inlet-and Pamlico Tyrrell and Washington Counties)
Counties)
Elizabeth City District Wilmington District
401 S. Griffin St. 127 Cardinal Drive Ext.
Ste. 300 Wilmington, NC 28405-3845
Elizabeth City, NC 27909 910-796-7215
252-264-3901 Fax: [phone]
Fax: [phone] (Serves: Brunswick, New Hanover,
(Serves:Camden,Chowan,Currituck, Onslow-South of New River Inlet-
Dare,Gates, Pasquotank and Perquimans and Pender Counties)
Counties)
http://portal.ncdenr.org/web/cm/dcm-home
Revised 7/06/17

1xcAMA/ ❑DREDGE & FILL - I'� f n 5.� NO '�(�oot� © C D
1 .11-1
GENERAL PERMIT 1/ v Previous permit# /l/�
.f\lew ❑Modification ❑Complete Reissue El Partial Reissue Date previous permit issued (\J� v%
As authorized by the State of North Carolina,Department of Environmental Quality
and the Coastal Resources Commission in an area of environmental concern pursuant to I 5A NCAC 0 1 14 , 12.00 .
/ -'{� Rules attached.
Applicant Name Sohn \�h C, .h \\ Project Location: County I;,r re I/
Address 6I0 I(0 )e 4 e r sa n 1v 0 - Street Address/State Road/Lot#(s)
City 1%(,eaefNLK State!YIP ZIP a)3953 ss A ) b,,o )c.r ie S hd-re €x4
Phone# (301 ) 112- � n E-Mail 1-ehv+sgAQUA tjNYposj.toA'1 Subdivision t U e 1 \O flt Shoec
Authorized Agent V t 6 a U 1 KhPat S W i ✓/ 41)C)(r y W i/L City L0I Ui'y1 b I CA ZIP q,--19Q5
Affected ❑CW ME TA ❑ES ❑PTS Phone# (30 I ) 412 -3-DZ'{- River Basin J S�to 4 4 r'
❑OEA ❑HHF ❑IH ❑UBA ❑N/A --,
AEC s : Adj.Wtr. Body Q 5 �Ccl na /man /unkn)
❑ PWS:
Closest Maj.Wtr. Body ) I b e'rY7Qf/f s°"'.-i
ORW: yes (no PNA yes /0
Type of Project/Activity P'T y./ rt. zoc,c //1 5144 i/ ,,,, x p .-r w/ a /2 it IL' p/ii t AT e eel w
,/ /,( /l�4 iow44 - `' /,x/Z' E,.. -- pier a r'rat• e$154 '1 (Scale: I" - 3u )
10
Pier(dock)length AP loCr g r,Y
Fixed Platform(s)J Z X I6i X IZ' Q u (1 S �A y ;
`1
Floating Platform(s) �/ i
)2. -
1
Finger pier(s) t}• 7f
Groin length
i
number tia- - -
y
' ' 1 � i 1
Bulkhead/Riprap length ` —_.- I -----._r f t\���
avg distance offshore i Q
max distance offshore
Basin,channel t '
{ e La
cubic yards I , i : l j
I Boat ramp I j
Boathouse/Boatlift _._. ....� .... _._.._.._..r......._.r--._._.......1.............._ _......._.........._....._.__r-__frS.......... __._...._..._._.._......--- - .....�_
I t y:
i
Beach Bulldozing - 41 IL -
Other ,�� 1/LAa 0L �,1 I
•
Shoreline Length I l �O ` ' I i �� y
0lk _4 eae:
SAV: snot sure yes no —._ 1�,� 71........................................ -
Photos: ir'Moratorium: n/a yes p� 1 yes no ^_ _ —._.; I
Waiver Attached: yes no 11 1 , , , , ,
„ ,
A building permit may be required by: fr( )' (.�GU/111/ Li See note on back regarding River Basin rules.
(Note Local Planning Jurisdiction
t , 1 ,4,,1 L k/ R. not t� (Ic eec� 10' Lf#,,,(,,,
Notes/Special Conditions C 5 1tlC� ! /) . '��rQ
i46)lley &'arily
Agent or Applicant Printed Name Perrtjit0 I r s Printed Nam
Signature **Please read compliance statement on back of permit** Signature
CMK •P 12w, 3014 / 3 - 'San - 2O7.1 — i3 - may- zaz,
Application Fee(s) Check# Issuing Date Expiration Date

Statement of Compliance and Consistency
This permit is subject to compliance with this application, site drawing and attached general and specific conditions. Any
violation of these terms may subject the permittee to a fine or criminal or civil action; and may cause the permit to become
null and void.
This permit must be on the project site and accessible to the permit officer when the project is inspected for compliance. The
applicant certifies by signing this permit that I)prior to undertaking any activities authorized by this permit,the applicant will
confer with appropriate local authorities to confirm that this project is consistent with the local land use plan and all local
ordinances, and 2) a written statement or certified mail return receipt has been obtained from the adjacent riparian
landowner(s).
The State of North Carolina and the Division of Coastal Management, in issuing this permit under the best available
information and belief,certify that this project is consistent with the North Carolina Coastal Management Program.
River Basin Rules Applicable To Your Project:
Tar-Pamlico River Basin Buffer Rules Other:
Neuse River Basin Buffer Rules
If indicated on front of permit,your project is subject to the Environmental Management Commission's Buffer Rules for the
River Basin checked above due to its location within that River Basin. These buffer rules are enforced by the NC Division of
Water Resources. Contact the Division of Water Resources at the Washington Regional Office (252-946-648 I) or the
Wilmington Regional Office(9 I 0-796-72 15)for more information on how to comply with these buffer rules.
Division of Coastal Management Offices
Morehead City Headquarters Washington District
400 Commerce Ave 943 Washington Square Mall
Morehead City, NC 28557 Washington, NC 27889
252-808-2808/ I-888-4RCOAST 252-946-6481
Fax: [phone] Fax: [phone]
(Serves:Carteret,Craven,Onslow- (Serves: Beaufort, Bertie, Hertford, Hyde,
North of New River Inlet-and Pamlico Tyrrell and Washington Counties)
Counties)
Elizabeth City District Wilmington District
401 S. Griffin St. 127 Cardinal Drive Ext.
Ste. 300 Wilmington, NC 28405-3845
Elizabeth City, NC 27909 910-796-7215
252-264-3901 Fax: [phone]
Fax: [phone] (Serves: Brunswick, New Hanover,
(Serves:Camden,Chowan,Currituck, Onslow-South of New River Inlet-
Dare,Gates, Pasquotank and Perquimans and Pender Counties)
Counties)
http://portal.ncdenr.org/web/cm/dcm-home
Revised 7/06/17

-- I
NCAMA / _I DREDGE & FILL -I.: 7 r '. r N° 79004 A B C D
GENERAL PERMIT Previous permit#
)ram .New ❑Modification =JComplete Reissue ❑Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC .
-' 0 Rules attached.
Applicant Name J t�\--'r- \G C. ki Project Location: County
' Address it„,« -t '7 C C "">c t 1 `- V 6 . Street Address/State Road/Lot#(s)
r'
City '-' -c. . ti State,r! U- ZIP 13{/ '? ., , j i
Phone#(301 ) 112- 1,fin 3 E-Mail Sa►.06 ulMA 4pfY poeI.' A'f Subdivision A`1je r-1 O r<r .56 o(( 1
Authorized Agent Ti C.E., ts\, .ro '., / 1)1 City r ZIP
Affected E Cw ®EW IOTA }❑ES / ❑PTS Phone# (3o I ) ' 12 -302-/ River Basin ,
❑OEA ❑HHF ❑IH ❑UBA ❑N/A
AEC(s): Adj.Wtr. Body +,,,`\S "F7c-,V (nat /man /unkn)
❑ PWS:
ORW: yes / no PNA yes /a no Closest Maj.Wtr. Body '1 -y
Type of Project/Activity .,
. ;,. e 4 . (Scale: ! , )t� )
Pier(dock)length 6;moptoo' ---
Fixed Platform(s)12 X lb', 7 X,Z, tj U ( 1 S t3 6; / I i
I ! 1
Floating Platform(s) """��
Finger pier(s) 4 X . 11-
Groin length1\1 i I
number — - - i
Bulkhead/Riprap length -
avg distance offshore �1 1 -
max distance offshore I
✓
Basin,channel ��I "w: ' I ' „1 I 1
f �, JH'
i i
cubic yards I 1 1
Boat ramp f
i
Boathouse/Boatlift — +— % .Y"_ r _ •. . r
t ;..... �. �...... _ -
l ! j
-
Beach Bulldozing "; 1._.. _
Other }It l. ( f
• �c�i.Gi v' ,, — i}I d i I l 1 1 1
T •
Shoreline Length-- 1 t , I�4 '` ` j f 11 i b,.t--+ i LJ i t r-
SAV: not sure yes no - Q ---. _.-_ __.._-. A -l'i/Ti ,1 ,
Moratorium: n/a yes no,. y p0 ,p } faCC, CRG y + ----1
fir__. . .___ ...... .._.__ ....-----._ _.i.. ._. _ ....�- `- .._......_ i
Photos: yes no 1_"/� '
Waiver Attached: yes no -
A building permit may be required by: J y ,(f // .t r, 1'/ I I See note on back regarding River Basin rules.
(Note Local Planning Jurisdiction)
Notes/Special Conditions R L..;/I , r= 0f t--=, 'Y t foe,'foe,' t C.
to.._ ILE, LA,
).,tit ley 6(-4#17)
Agent or Applicant Printed Name Permit Officers Printed Nam
J "LeAf--41e,--
Signaturee **Please read compliance statement on back of permit** Signature G J
t 12 C. t / 3 - ., 2OZ► - ,3 - /Yid,- 202 1
Application Fee(s) Check# Issuing Date Expiration Date

Statement of Compliance and Consistency
This permit is subject to compliance with this application, site drawing and attached general and specific conditions. Any
violation of these terms may subject the permittee to a fine or criminal or civil action; and may cause the permit to become
null and void.
This permit must be on the project site and accessible to the permit officer when the project is inspected for compliance. The
applicant certifies by signing this permit that I)prior to undertaking any activities authorized by this permit,the applicant will
confer with appropriate local authorities to confirm that this project is consistent with the local land use plan and all local
ordinances, and 2) a written statement or certified mail return receipt has been obtained from the adjacent riparian
landowner(s).
The State of North Carolina and the Division of Coastal Management, in issuing this permit under the best available
information and belief,certify that this project is consistent with the North Carolina Coastal Management Program.
River Basin Rules Applicable To Your Project:
Tar-Pamlico River Basin Buffer Rules Other:
Neuse River Basin Buffer Rules
If indicated on front of permit,your project is subject to the Environmental Management Commission's Buffer Rules for the
River Basin checked above due to its location within that River Basin. These buffer rules are enforced by the NC Division of
Water Resources. Contact the Division of Water Resources at the Washington Regional Office (252-946-648 I) or the
Wilmington Regional Office(9 I 0-796-7215)for more information on how to comply with these buffer rules.
Division of Coastal Management Offices
Morehead City Headquarters Washington District
400 Commerce Ave 943 Washington Square Mall
Morehead City, NC 28557 Washington, NC 27889
252-808-2808/ I-888-4RCOAST 252-946-648 I
Fax: [phone] Fax: [phone]
(Serves:Carteret,Craven,Onslow- (Serves: Beaufort, Bertie, Hertford, Hyde,
North of New River Inlet-and Pamlico Tyrrell and Washington Counties)
Counties)
Elizabeth City District Wilmington District
401 S. Griffin St. 127 Cardinal Drive Ext.
Ste. 300 Wilmington, NC 28405-3845
Elizabeth City, NC 27909 910-796-7215
252-264-3901 Fax: [phone]
Fax: [phone] (Serves: Brunswick,New Hanover,
(Serves:Camden,Chowan,Currituck, Onslow-South of New River Inlet-
Dare,Gates, Pasquotank and Perquimans and Pender Counties)
Counties)
http://portal.ncdenr.org/web/cm/dcm-home
Revised 7/06/17

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Hello,
Your neighbor John Kosch at 88 Albemarle shore ext. in
Colombia, NC, are planning to have their Rip Rap repaired and
a Pier built. They have hired us (DandB Bulkeads) to construct
the work. This letter if to notify of the proposed work.
I have included a sketch and a Cama form with this letter.
The sketch is to show you the proposed pier construction on
their property.
I have marked on the Cama form two places for your signature
and one place for your initials. This simply shows that you have
no objections to the proposed work and have been informed of
it.
If you could, please sign and send back the Cama form to the
address below.
: DandB Bulkheads
1505 Goldie St. Unit C, kill devil hills, NC 27948
If you have any questions or concerns please feel free to call
me at anytime.
Dan A. : 252-455-6322
Thank you.
Dan A.
DandB Bulkheads

DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
CERTIFIED MAIL • RETURN RECEIPT REQUESTED or HAND DELIVERED
Name of Property Owner: ,John it`s,57/`ry
Address of Property: 459g hib fl (t° ch.-te5 eA T, ) (o/c-n 4IM NL
(Lot or StreeteJ #, Street or Road, City &County)
Agent's Name #: �dhl�` 4-�►ri',i iwtr2 Mailing Address:
15d 5* G a ietie sr; v47>c C
Kul del! /►HII1 )rvc 2-7. ,
Agent's phone #: _S?- 465""'r j.t 2
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 401 S. Griffin St., Ste 300, Elizabeth City, NC, 27909. DCM representatives can also be
contacted at(252) 264-3901. 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, 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 sign the appropriate blank below_)
I do wish to waive the 15' setback requirement.
s i do not wish to waive the 15' setback requirement.
(Property Owner Information) (Adjacent Property Owner Information)
lfv
gnature Signature*
Toil i kas(h CAarie'5 Ycino5k?I ' Eet,� ( cIfl9
Print or Type Name Print or Type Name
616 3c' FE'r580 B1Jd, 5 kluc( 5'r l L~r'1,? y Al* 3 ;
Mailing Address Mailing Address
D 21703

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Tracking Number: 70201290000228047864 Remove X
Your item was delivered to an individual at the address at 11:52 am on December 30, 2020 in
GRANBY, MA 01033.
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December 30, 2020 at 11:52 am
Delivered, Left with Individual
GRANBY, MA 01033
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DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
CERTIFIED MAIL - RETURN RECEIPT REQUESTED or HAND DELIVERED
Name of Property Owner: fi,?j1,' 5 a}
Address of Property: t'A ; (o/yin-hrir Nt
(Lot or Street#, Street or Road, City& County)
Agent's Name #: Qdn i Fl A- /Becd;vtr2 Mailing Address:
/c /(dM1 /rtr`6 /1/4- 2.7?kf
Agent's phone #: 9 Q-- 663. +j)2
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 401 S. Griffin St., Ste 300, Elizabeth City, NC, 27909_ DCM representatives can also be
contacted at(252) 264-3901. 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, 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 sign 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 Information) (Adjacent Property Owner Information)
k-/41 —)
Signature Signature*
Tr2:1111 h 05(11 W►lrer Lea lye 4- (1,r;5fy 514vf
Print or Type- Name p Print or Type Name
il' TCYPz9r5©ti IJw/ 227 54/Of A/1fCr?5 v�� Rrn�l,1 //) 21C12
Mailing Address Mailing Address
Fr i ff/Or 111 131 217o 3

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Tracking Number: 70201290000228047871
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Your item was delivered to an individual at the address at 1:00 pm on December 24, 2020 in
ARNOLD, MD 21012.
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December 24, 2020 at 1:00 pm 'c
Delivered, Left with Individual
ARNOLD, MD 21012
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