79260A_Mew, Andea_20210614

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GENERAL PERMIT Pmvkuspwn*
;SNew ZModlficsdan CComplate Relnue CP&rtlal Reissue Date previous permit Issued
As authoi by the State of North C"h a, Deparwmm or EmAronmwW QwAty t }
and the C =tW Piummu Commission In an area of emArorvrwW concern pursuant to 15A NCA C 1100
R.iM atuthad.
Appilcam Name- A V%Je.a t-teW _ P
Add. ! 513 `?ark IJ*& _I,. Straat Address/ Saba R=W Lot #(a) L.o� ,?y
__ ra; �'► state_NCz1P 2161y _. !{p ta.r �. !'
Phone a# (!M) - 57gPE-Mal &PJen , if"ttlta&�t�Ctwtt�,teSubdivlsion
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Af%cted ❑ CW ISM K IRA 5aEs i1pTs Phone # { i) �_.� � River Basin p*&# A i^ier k—
AEC:(s): O ❑ HHF ❑ IH ❑ U8A 17 WA
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Name of Property Owner Requesting Permit: A nx1 co. Mp o.
Mailing Address: 1.
J
t� C —t c.o t -e
Phone Number: 8C> - `E) {
Email Address:
I certify that I have authorized P r Lo"-1
Agent t Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:X,Dng- �6C11Q��`1Z �'
at my property located at t I t See- '� { f � � f t`Q C X 7 -, A ; .
in C,Vxxau i r-, County.
l furthermore certify that / 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:
Signature
ca..._ I`"{.
Print or Type Name
rVA5•
Tide
�.`
Date
This cartilkation is valid through ! !

l hereby certify that i own property adjacent to '*11-144eo L' {!A Fa
r' (Naffle o4 Property O
property located at . U r-Id� -- • - -- -
Addraw, Lot, Block. Road, etc.)
on -,.� l-+ram-1'� . r► , r Le -{ rt J*J,. _ N.C.
(Watsrbody) (Cttyfrown and/or County)
The appoligant has described to me, as shown below, the development proposed at the above
kx�i have no objection to this proposal.
i have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(tndlvlduot proposing development must MI in description below or attach a she drawing)
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 yo `sh to waive the setback, you must initial the appropriate blank below.)
7i do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Ownt►r Information] �,4A party Owner Information)
Sir a } 'tune *
hHnt or ryp. Name Print or Name
Addres A'fa ,bra
CltylState" $0 — r70 , - Z. GsY i o c,r•
Telep b t email address telephone um rl small address
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11
Dom
(Revised Aug. 2014)
*Valid for one calendar year after signature'

a, ► ► r � �-nazi.= a3. � '�
S
I hereby certify that I own property adjacent to n ndel2�-
property Located at � llQ (Name of Property Owner)
(Address, Lot, Bloc*, Road, etc.)
on _AA be tsar 1� ` � in N.C.
(Watery) (Cltyi'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.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(individual proposing development must Mil In description below or attach a skits drawing)
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. (lf yn ski to waive the setback, you must Initial 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) .
SYRnature
e
PrOt or Type Nerne
151 -2�1 9__i___
1f6t#krg Address �
NC 31,71
y/SiBdC .�fp
T&Whc Number/small address
2,--
Date
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t'ffY1%xarM 1-1P
Tili j ' Number 1 emalt address
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