Gaskins, Perry 78237C

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As by the Sate of North Carolina, Department of Environmenal Quality
and the Coastal Commission io an area environmental concern pursuant to I 5A
Applicant L I Project Location:
Street
Phone #
N9 78237
Previous permit
Road/ Lot
permit issued
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Closest Mai. Wtr. Body
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Basin
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Type of ProiecU Activity
I ii (Scale:)
Pier (dock)
Fixed Platform(s)
Floating Platform(O Y--
F{nger Per(s)
Groin lengh
Bulkhead/
a6 distarre ofbhore
max disance
Basin,channel--
'.'--cuDlc raros_iil
Boat
Boadrouse/
Beadr
Other
Shoreline Length
SAV: notsur€
Moratorium: ry'a
Photos:
Waiv€rAttacH:
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yes
yes
yes
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A building permit may be required Ds*on back regarding River Basin rules.
( Note [ocal Planning
Noted Special
Fee(s)
read on back
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Date Date
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Authorized
Affected
AEC(s):NOEA
Phone #
Adi. Wtr.
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Name of Property Owner Requesting Permit:
Mailing Address:I Lo oa.,>3 tr/
Stor-*r-., i/lt 7*I
Phone Number:
Email Address:
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I certify that I have authorized v.,1,t t L
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
Agent / Contractor merL . Oo/n
w$l,t
at my property loca,ledat ILn nal,o t t,, B ea.etua1 zLz l-*4 L ,
in o,*oa*"p7:County.
I furthermore certity that I am authoized to grant, and do in fact grant permission to
Division of Coastal Management staff, the Local Permit Officer and their agents to enter
on the aforementioned lands in connection with evaluating information related to this
permit application.
Property Owner lnformation:
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P'rint or Type Name
lo t /
Date
This certification is valid through {
AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
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ADJACENT RIPARIAN PROPERTY OUVI{ER STATEMENT
I hereby certifo that I own property adjacent b Pi.P$Y btspr,c)
(Name of Property Oruner)
property located at leb ntu, s t,u
's
(Address, Lot, Bloclq Road, etc.)
on tn v 'N.C.
(Waterbody)own and/or County)
The applicant has described to me, as shown below, the development poposed at the above
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I have objections to this proposal
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_ | do wish to waive the 15' setbach requirement
I do not wish to waive the 15' setback requirement.
(Property Orner
I understand that a pier, oo*, ,n**ffi.ru*, ,"*, breakwater, boathouse, Iift, or groin
must be set back a minimum distance of i5'from my area of riparian access unless waivei by
me- (lf you wish to waive the setback, you must initiil the appropdate blank below-)
(AdFcant Property Owner lnformaf on)
Pint or TyF Nameg,o, B o* L7fl
Mailing ,/qddtBss
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Pdnt ot TtW Name
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Mailing
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Telephone Number / emait address
,-.u'-,ln Tdeplwle Numtpr / wmil afircss
Date
l/alid for one calendar ]rear after signature'
Ddlel
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(Revised Aug. 2014)
OESCRIPNOil AiID'OR ORAwliTG OF PROPOSED DEI/ELOPiIENT
(rt ttMdual prop.qing <levetopment must frtt in &suiption blw or abch a site dftwing)
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