Davis, Robbie 80023C

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and the Coastal Recourtcs
o[ North Carpllrs, Dcertrrgtt of E wlrorrllc,rtll Quality
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This Permit is subiec b comciane 16 ar'*"ppli.ton, slE drawing and dtafu tenGral and speciftc condidms. Arryviolaion of these Errrs mry s,q*t fre perrnd;;;;;;;minat or civir action; ard rray carse the porrnit to bccoflEnullandvoid. ir,rsv, vv.r ctuvrr; anq lrlay car
This P€rmit must bc on the proilctsfrE md aes{ble to the perrrit offqwhen the proi*t ls in+ectc<, for complhncc. TheaPPlicant cert'ftes by sitni'E dtb p€rmt ont r ) prioro undertaiing any.crivitios ardtorized bydris permic the +plicant u,illconfer with appropriae local audprioes o "lltnt auG p-t.o is conr*stent with dr. l[l l"rrd ,." plan and a[ hcarffiHffi.il 2) a uritten sEEnrent or certilied mail rrl; rlcdF has becn oH'ledfrom itn adirent riparian
Th€ h d Nord @,- t.F Divbion of C-oa*rl Marqgem.rrt, in issuint dris permit under the best *aibHeinforrruionandbelief'cerdrydtddtbp-i*tr-,"rra",tt*ur_dNordrcarolimcestelllamgern€.rtprogrin.
lf indicacd on frront of pcrrn! yor propct is sublGd to drc Erwircnnudal Marqg..r*rt commission,s &rfier ful€ for d..Riv€r Bssi't drGd(€d abov'e drr to ls toaion
"arii, t * lu*r g.Jn. mese uurJ rules
"r" Jo..! uy o. NC Dtutson ofWaer Raources' contact the Dffiion of wter Resourcee d dle wa$irEton RqiotE omce @52-g{G6rs l) or trre\MlmirEtonR€gio.tarome(9lG79672rsyformore#onifrI-onr,*o.di"eryfit-o',-":u,F*-1"".
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lr{clpd CitI }lEd+er.rrn
.100 C-onunerce Are
f,brehaad City, l.lC 28557
252{82808/ | {8&,TRCOAST
Fax [phone]
(S€n E Crra.t.' Cr.l,rrr' Odotfl -
Nordt d tlsri Rilrlr Lrlct. rd Purlco
CouOec)
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,()1 S. Grifin St.
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Elbbeth GtI, t{C 27909
252-264390t
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(Sstrs: Cafitdr1 Orrrzq Gfiiudq
Dan, Gc, Prqu€d( d PCrqrtuanr
Cantle)
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lValhltgton Dfutiict
9{3 Wasttington Sqrnre Mall
Wa$ington, NC 2789,
252-916{,a1
Fax,7S2-9M78
(Sdvt: Eafrr! B.rde FL.r6.d, Fi/de
lErrldWd*gron Corrd6)
tlVflmlqton DLolct
127 Crrdid Driw Ext.
Wlmirgton, NC 28/O5-:l&{5
9tan("zl+s
Fax 91G395-396{
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and Ftndcr CourCres)
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N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date
Name of Property Owner Applying for Permit:
Mailing Address:
I certify that I have euthorized (agent).Jrsrrr, Pmru Jmtl /tt rl^c to act on mY
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activitY)D
at (my proPertY located at)
This certifrcation is valid thru (date)
o
u
Date
Prop Signature
/
ADJACENT RIPARIAN PROP ERTY OWNER ST TEMENT
I hereby certify that I own prope(y adjacent to 4ab c_
property located at 0 of Pr e rty Owner)(
on 0 Y-A-
(Address,R
tn 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
S
DESCR IPTION AND/OR DRAWNG OF PROPOSED DEVELOPMENT
p'4tttttEilffiffid,4"b #e*r*€err.tb *avlrq)
/e'x 32
QoeR
a
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t^Jat W,-LI
WAIVER SECTION
l understand that a pier, docr, .oorintliiiilE]I6;iil p' breakwater' boathouse' lift' or groin
must be set back a minimum dil;;;"J iarfr"m my area of riparian access unless waived by
.". iriv* *i"n t waive the seGck, you must initi;l the appropriate blank below')
I do wish to waive the 15'setback requirement'
I do not wish to waive the 15' setback requirement
cent Property Own formatlon)er
(Property Owner I
ature
e_
ation)
gna
or Name4t-
Pint or
0
IU
te/Zip 7t-
e Number email address / email address
,1 a30
DoIe
*Valid for one calendar year after signature*
Numbet
(Revised Aug. 2014)
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ADJACENT RIPARIAN PROPE RTY OWNER STATEMENT
I hereby certify that I own property adjacent to
property located at
Address,Lot
(Name of Property Owner)
S
onG re vopV ln R a
Road, etc.)
F{r , N.C.
(Waterbody)(City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
locatioA.
t / I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRA WNG OF PROPOSED DEVELOPMENT
/e'x 32'
QocR
Extt'
so/'{;d
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I do wish to waive the 15' setback requirement'
I do not wish to waive the 15' setback requirement'
r^ntK w.1
acent Property Owner I ion)
WAIVER SECTION
I understand that a pier, dock, moo,inE-6'iiii s, boat ramp' breakwater' boathouse' lift' or groin
,rri-n"'""iUr"r a minimum d;";;;;"J lsifrom my area of riparian agces: Ynle:s waived by
.". ifiv* *l"n to waive the seGck, you must initiil tne appropriate blank below )
(Prope Owner lnformation)
s,nature
Pint or Name
A
tp
Telephone Number / email address
'2.-A)-al
a
Pint or Name
ss :r
D 60t5
c.
o
er / email address
Date
'Valid for one calendar year after signature*
Dale+
d -Al
(Revised Aug. 2014)
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