SC_21-12_ Mix (2)

r .
Issued by WiRO RECEIVED SC21-12
•
Permit Number
Surf City JUN 0 3 202.
CAMA M.WLMINGTON, NC
MINOR DEVELOP1EN ,
PERMIT
NORTH CAROLINA
Environmental Quality
as authorized by the State of North Carolina, Department of Environmental Quality
and the Coastal Resources Commission for development in an area of environment
concern pursuant to Section 113A-118 of the General Statutes, "Coastal Area
Management"
Issued to Thomas and Kelly Mix authorizing development in the Estuarine Shoreline (AEC) at 109 Oleander Court in
Surf City, Pender County as requested in the permittee's application, dated April 20, 2021, and received as complete by
DCM on April 23, 2021. This permit, issued on May 12, 2021, is subject to compliance with the application and drawing
dated and received by DCM on April 23, 2021 (where consistent with the permit), all applicable regulations and special
conditions and notes set forth below. Any violation of these terms may subject the permittee to a fine, imprisonment or
civil action, or may cause the permit to be null and void.
This permit authorizes: Construction of a single family residence with amenities.
(1) All proposed development and associated construction must be done in accordance with the permitted site drawing dated
received by DCM on April 23, 2021.
(2) Any change or changes in the plans for development, construction, and/or land use activities will require re-evaluation and
modification of this permit.
(3) A copy of this permit shall be posted or available on site throughout the construction process. Contact this office at(910)
766-7221 for a final inspection at completion of work.
(Additional Permit Conditions on Page 2)
This permit action may be appealed by the permittee or other qualified persons
within twenty (20) days of the issuing date. This permit must be on the project
site and accessible to the permit officer when the project is inspected for Jason ail
compliance. Any maintenance work or project modification not covered under CAMA LOCAL PERMIT OFFICIAL
this permit,require further written permit approval.All work must cease when this 127 Cardinal Drive Extension
permit expires on:
Wilmington, NC 28405-3845
December 31,2024
In issuing this permit it is agreed that this project is consistent with the local Land
Use Plan and all applicable ordinances. This permit may not be transferred to
another party without the written approval of the Division of Coastal PERMITTEE

Name: Thomas and Kelly Mix
Minor Permit#SC21-12
Date: May 12, 2021
Page 2 of 2
(4) All unconsolidated material resulting from associated grading and landscaping shall be retained on site by effective
sedimentation and erosion control measures. Disturbed areas shall be vegetated and stabilized (planted and
mulched)within 14 days of construction completion.
(5) Any proposed for grading within the 30' Coastal Shoreline buffer (as measured from the Normal High Water level)
must be contoured to prevent additional stormwater runoff to the adjacent marsh and/or canal. This area shall be
immediately vegetated and stabilized and must remain in a vegetated state.
(6) All development shall be located at least 30' landward of the normal/mean high water line. No impervious
coverage/built upon area, including but not limited to the house (including eaves), swimming pool, pool
decking, coping/apron foundation pad, covered decking. etc. shall extend into the 30-foot coastal shoreline
buffer.
(7) This permit does not authorize the excavation or filling of any wetlands, even temporarily.
(8) All structures shall comply with the NC Building Code, including the Coastal and Flood Plain Construction Standards
of the N. C. Building Code, and the Local Flood Damage Prevention Ordinance as required by the National Flood
Insurance Program. If any provisions of the building code or a flood damage prevention ordinance are inconsistent
with any of the following AEC standards, the more restrictive provision shall control.
(9) Pursuant to 15A NCAC, Subchapter 7J.0406(b), this permit may not be assigned, transferred, sold or otherwise
disposed of to a third-party.
SIGNATURE: DATE: y yA
20
PERMITTEE
f

OTHER PERMITS MAY BE REQUIRED:The activity you are planning may require permits other than the CAMA
��'o ,L,kJ y Permit Number s I r� minor development permit,including,but not limited to:Drinking Water Well,Septic Tank(or other sanitary waste
-- o treatment system),Building,Electrical,Plumbing,Heating and Air Conditioning,Insulation and Energy Conservation,FIA
I Estuarine Shoreline k ORW Shoreline Public Trust Shoreline Other CtherscCheckSand
d our Dune,Local PermitSediment
OfficerOffice ol,Subdivisionr ore int Approval,
Mobile Home Park Approval,Highway Connection,and
o'\ (For official use only)
STATEMENT OF OWNERSHIP:
INFORMATION I,the undersigned,an applicant for a CAMA minor development permit,being either the owner of property in an AEC or a
IER person authorized to act as an agent for purposes of applying for a CAMA minor development permit,certify that the person
listed as landowner on this application has a significant interest in the real property described therein.This interest can be
s Mix and wife,Kelly Mix — described as:(check one)
Oleander Court 4727
I✓Ian owner or record title,Title is vested in Fee Simple __ _,see Deed Book
State Nc Zip 28415 Phone [phone] page 2700 in the Pender __ County Registry of Deeds.
[e-mail] -- - - Flan owner by virtue of inheritance.Applicant is an heir to the estate of
probate was in County.
MD AGENT
les F.Riggs&Associates,Inc. f other interest,such as written contract or lease,explain below or use a separate sheet&attach to this application.
O.Box 1570 NOTIFICATION OF ADJACENT PROPERTY OWNERS:
p 28541 Phone [phone] I furthermore certify that the following persons are owners of properties adjoining this property.I affirm that I have given
Dnvllle State NC Zi ACTUAL NOTICE to each of them concerning my intent to develop this property and to apply for a CAMA permit.
[e-mail] (Name) (Address)
(I) Bland Shores HOA,P 0 Box 2364,Surf City,NC 28445
N OF PROJECT:(Address,street name and/or directions to site.If not oceanfront,what is the name of the (2) James Malcolm Hall,III,P O Box 2706,Surf City,NC 28445
terbody.)109 Oleander Court,Surf City,Pender County(Parcel 4223-48-6157-0000)
(3) Lucky Dog Real Estate,LLC,2507 Woodbine Road,Winston Salem,NC 27104
fiON OF PROJECT:(List all proposed construction and land disturbance.) Proposed Two-Story (4) -- -- -" —
I on Pilings with Decks Over Concrete Slab Partially Enclosed below for Entry,Storage and
.OT/PARCEL: 9,404square feet 0.216 acresGarage with Proposed Pervious Drive ACKNOWLEDGEMENTS:
&Pool with Pool Decking&All Proposed Improvements Shown on Map I,the undersigned,acknowledge that the land owner is aware that the proposed development is planned for an area which
;D USE:Residential Q (Single-family Q Multi-family❑) Commercial/Industrial El Other 0 may be susceptible to erosion and/or flooding.I acknowledge that the Local Permit Officer has explained to me the particu-
lar hazard problems associated with this lot.This explanation was accompanied by recommendations concerning stabilize-
TE EITHER(1)OR(2)BELOW(Contact your Local Permit Officer ifyou are not sure which AEC applies lion and floodproofing techniques.
perry):
I furthermore certify that I am authorized to grant,and do in fact grant,permission to Division of Coastal Management staff,
,N HAZARD AECs:TOTAL FLOOR AREA OF PROPOSED STRUCTURE:N/A square feet(includes the Local Permit Officer and their agents to enter on the aforementioned lands in connection with evaluating information
med living space,parking elevated above ground level,non-conditioned space elevated above ground level but related to this permit application.
non-load-bearing attic space) D This the /J`©r/i day of+Ai�',20 Z"
iTAL SHORELINE AECs:SIZE OF BUILDING FOOTPRIN-I'AND OTHER IMPERVIOUS ORBUILT C /'�r/' �
RFACES: 931 square feet(includes the area of the roof/drip line of all buildings,driveways,covered decks, ---
r masonry patios,etc.that are within the applicable AEC.Attach your calculations with the project drawing.) Landowner or person authorized to act as his/her _)1 1'oripurpo' f filing a CAMA permit application
i'ORMWATER MANAGEMENT PERMIT:Is the project located in an area subject to a State Stormwater
This application includes:general information form),a site drawing as described on the back of this application,the
ent Permit issued by the NC Division of Water Quality? ownership statement,the Ocean Hazard AEC Notice where necessary,a check/br$100.00 made payable to the locality.and
] NOI I any information as may be provided orally by the applicant.The details of the application as described by these sources are
the total built upon area/impervious surface allowed for your lot or parcel:2,035 square feet. incorporated without reference in any permit which may be issued.Deviation from these details will constitute a violation of
any permit.Any person developing in an AEC without permit is subject to civil,criminal and administrative action.
RECEIVED
ipR23 2021
DCM WILMINGTON; VC

;, swE a;f)y'
ROY COOPER
Governor nb .r
ELLI-GATTI � .
DIONNE D
Secretary -_-
BRAXTON DAVIS NORTH CAROLINA
Director Environmental Quality
May 12, 2021
Thomas& Kelly Mix
109 Oleander Court
Surf City, NC 28445
Dear Mr. & Mrs. Mix,
Attached is CAMA Minor Development Permit SC 21-12 for work to be done at 109 Oleander Court in
Surf City, Pender County. An electronic copy has been sent to the Surf City Inspections Department and
your Agent.
To validate this permit, please sign both copies as indicated for our records. Retain the gold copy for
your files, and return the white copy to us within 20 days of receipt in the enclosed, self-addressed
envelope.
This is not a valid permit until it is signed and returned to our office.
Thank you for your prompt attention to this matter.
Sincerely,
I
(j)//
1-1L /(,LLBebh
Anita M.Webb
Permit Support Technician
N.C. Division of Coastal Management
Enclosures
Cc: WiRO files
SC Inspection Dept.
Charles F. Riggs &Associates, Inc.—Agent
North Carolina Department of Environmental Quality I Division of Coastal Management
a .ti r ...r.,.. 7RAa 17%2946.6481

CHARLES F. RIGGS &ASSOCIATES, INC.
Land Surveyors
Charles F.Riggs,P.L.S.L-2981 Corporate License(C-730) James A.Lewis,P.L.S.L-4562
502 New Bridge Street 502 New Bridge Street Landfall Executive Suites
Jacksonville,North Carolina 28540 P.O.Box 1570 1213 Culbreth Drive
[phone] Jacksonville,North Carolina 28541 Wilmington,North Carolina 28405
[e-mail] [phone] [phone]
www.riggslandnc.com [e-mail]
April 20,2021
To: Mr. Jason Dail
Division of Coastal Management
North Carolina Department of Environmental Quality
127 Cardinal Drive
Wilmington,North Carolina 28405
Re: Thomas Mix and wife,Kelly Mix Submittal for Minor CAMA Permit
Dear Mr. Dail:
On behalf of Thomas Mix and wife, Kelly Mix,Charles F. Riggs&Associates, Inc. submits for your
review the enclosed application for a Minor CAMA permit for the property at 109 Oleander Court, Surf
City,Pender County,North Carolina(Parcel 4223-48-6157-0000.)
pectfully,
� J
/)�
James L. Riggs
RECEIVED
APR 2 3 20 1
DCM WILMINGTON, NC

CHARLES F. RIGGS &ASSOCIATES, INC.
Land Surveyors
Charles F.Riggs,P.L.S.L-2981 Corporate License(C-730) James A.Lewis,P.L.S.L-4562
502 New Bridge Street 502 New Bridge Street Landfall Executive Suites
Jacksonville,North Carolina 28540 P.O.Box 1570 1213 Culbreth Drive
[phone] Jacksonville,North Carolina 28541 Wilmington,North Carolina 28405
[e-mail] [phone] [phone]
www.riggslandnc.com [e-mail]
April 20, 2021
Bland Shores HOA
P. O. Box 2364
Surf City,NC 28445
Re: Thomas Mix and wife,Kelly Mix Submittal for Minor CAMA Permit
To whom it may concern:
On behalf of Thomas Mix and wife, Kelly Mix,Charles F. Riggs&Associates, Inc. is submitting to
the Division of Coastal Management,North Carolina Department of Environmental Quality the enclosed
application for a CAMA permit for the property located at 109 Oleander Court, Surf City,Pender County,
North Carolina. Thomas Mix and wife, Kelly Mix are planning to construct a two-story dwelling on
pilings with decks over a concrete slab partially enclosed below for entry,storage and garage with a
pervious drive,a pool with pool decking and all proposed improvements,as shown on map. We are
required to notify the adjoiners of this submittal. If you have objections,please contact Mr.Jason Dail in
a timely manner at(910)796-7221,[e-mail],or by mail at the Division of Coastal
Management,N.C. Department of Environmental Quality, 127 Cardinal Drive,Wilmington,NC 28405.
R pectfully,
fin,_ I r
James L. Riggs
RECEIVED
APR 2 3 2021
DCM WILMINGTON NC

CHARLES F. RIGGS &ASSOCIATES, INC.
Land Surveyors
Charles F.Riggs,P.L.S.L-2981 Corporate License(C-730) James A.Lewis,P.L.S.L-4562
502 New Bridge Street 502 New Bridge Street Landfall Executive Suites
Jacksonville,North Carolina 28540 P.O.Box 1570 1213 Culbreth Drive
[phone] Jacksonville,North Carolina 28541 Wilmington,North Carolina 28405
[e-mail] [phone] [phone]
www.riggslandnc.com [e-mail]
April 20,2021
Mr. James Malcolm Hall, III
P. O. Box 2706
Surf City,NC 28445
Re: Thomas Mix and wife,Kelly Mix Submittal for Minor CAMA Permit
Dear Mr. Hall:
On behalf of Thomas Mix and wife, Kelly Mix,Charles F. Riggs&Associates, Inc. is submitting to
the Division of Coastal Management,North Carolina Department of Environmental Quality the enclosed
application for a CAMA permit for the property located at 109 Oleander Court, Surf City,Pender County,
North Carolina. Thomas Mix and wife, Kelly Mix are planning to construct a two-story dwelling on
pilings with decks over a concrete slab partially enclosed below for entry, storage and garage with a
pervious drive,a pool with pool decking and all proposed improvements,as shown on map. We are
required to notify the adjoiners of this submittal. If you have objections,please contact Mr. Jason Dail in
a timely manner at(910)796-7221,[e-mail],or by mail at the Division of Coastal
Management,N.C. Department of Environmental Quality, 127 Cardinal Drive,Wilmington,NC 28405.
Respectfully,
61riaa'i
James L. Riggs All
RECEIVED
APR 2 3 2021
..A.. \.I11 ..IL1/", ' .n.

CHARLES F. RIGGS &ASSOCIATES, INC.
Land Surveyors
Charles F.Riggs,P.L.S.L-2981 Corporate License(C-730) James A.Lewis,P.L.S.L-4562
502 New Bridge Street 502 New Bridge Street Landfall Executive Suites
Jacksonville,North Carolina 28540 P.O.Box 1570 1213 Culbreth Drive
[phone] Jacksonville,North Carolina 28541 Wilmington,North Carolina 28405
[e-mail] [phone] [phone]
www.riggslandnc.com [e-mail]
April 20, 2021
Lucky Dog Real Estate, LLC
2507 Woodbine Road
Winston Salem,NC 27104
Re: Thomas Mix and wife,Kelly Mix Submittal for Minor CAMA Permit
To whom it may concern:
On behalf of Thomas Mix and wife, Kelly Mix,Charles F. Riggs&Associates, Inc. is submitting to
the Division of Coastal Management,North Carolina Department of Environmental Quality the enclosed
application for a CAMA permit for the property located at 109 Oleander Court, Surf City, Pender County,
North Carolina. Thomas Mix and wife, Kelly Mix are planning to construct a two-story dwelling on
pilings with decks over a concrete slab partially enclosed below for entry, storage and garage with a
pervious drive,a pool with pool decking and all proposed improvements, as shown on map.We are
required to notify the adjoiners of this submittal. If you have objections,please contact Mr. Jason Dail in
a timely manner at(910)796-7221,[e-mail],or by mail at the Division of Coastal
Management,N.C. Department of Environmental Quality, 127 Cardinal Drive,Wilmington,NC 28405.
espectfully,
ha I
r-275)
James L. Riggs
RECEIVED
APR 2 3 2021

CHARLES F. RIGGS &ASSOCIATES, INC.
Land Surveyors
Charles F.Riggs,P.L.S.1,-2981 Corporate License(C-730) James A.Lewis,P.L.S.1.-4562
502 New Bridge Street 502 New Bridge Street Landfall Executive Suites
Jacksonville,North Carolina 28540 P.O.Box 1570 1213 Culbreth Drive
[phone] Jacksonville,North Carolina 28541 Wilmington,North Carolina 28405
charlesriggsariggslandnc.com [phone] [phone]
jameslcwis(i4riggs landnc.com
AGENT AUTHORIZATION FORM
Date: __April 14, 2021
Name of Property Owner Applying for Permit:
Thomas Mix and wife, Kelly Mix
Mailing Address:
109 Oleander Court
Surf City, NC 28445
I certify that 1 have authorized Charles F. Riggs & Associates, Inc. to act on my behalf, for the purpose
of applying for and obtaining all CAMA Permits necessary to install or construct proposed development, as
shown on attached map and located at 109 Oleander Court, Surf City, Pender County,North Carolina, and I
grant permission to the Division of Coastal Management to access the property to mark/flag:
X The First Line of Stable Natural Vegetation
X The Coastal Wetlands
X The Normal High Water Line
This authorization is valid thru April 14,2022
4 April 14, 2021
Property Owner Signature Date
RECEIVED
APR 2 3 Z021

OCEAN HAZARD AEC NOTICE
Project is in an: . Ocean Erodible Area High Hazard Flood Area inlet Hazard Area
Property Owner: Thomas Mix and wife,Kelly Mix
Property Address: 109 Oleander Court,Surf City,Pender County
Date Lot Was Platted: September 2002
this notice is intended to make you, the applicant,aware of die SPECIAL NOTE: This hazard notice is required for
special risks and conditions associated with development in this development in areas subject to sudden and massive storms and
area,which is subject to natural hazards such as storms.erosion erosion. Permits issued for development in this area expire on
and currents. The rules of the Coastal Resources Commission December 31 of the third year following the year in which the
require that you receive an AEC Hazard Notice and permit was issued. Shortly before work begins on the project
acknowledge that notice in writing before a permit for site.the Local Permit Officer must be contacted to determine the
development can be issued. vegetation line and setback distance at your site. If the property
has seen little change since the time of permit issuance,and the
The Commission's rules on building standards, oceanfront proposed development can still meet the setback requirement,
setbacks and dune alterations are designed to minimize,but not the LPO will inform you that you may begin work. Substantial
eliminate, property loss from hazards. By granting pear,its, the progress on the project must be made within 60 days of this
Coastal Resources Commission does not guarantee the safety of setback determination,or the setback must be re-measured Also,
the development and assumes no liability for future damage to the occurrence of a major shoreline change as the result of a
the development. Permits issued in the Ocean Hazard Area of storm within the 60-day period will necessitate re-measurement
Environmental Concern include the condition that structures be of the setback. It is important that you check with the LPO
relocated or dismantled if they become imminently threatened before the permit expires for official approval to continue the
by changes in shoreline configuration. The structure(s) must be work, after the permit has expired. Generally, if foundation
relocated or dismantled within two (2) years of becoming pilings have been placed and substantial progress is continuing,
imminently threatened, and in any case upon its collapse or permit renewal can be authorized. It is unlawful to continue
subsidence. work after permit expiration.
The best available information,as accepted by the Coastal For more information,contact:
Resources Commission, indicates that the annual long-term
average ocean erosion rate for the area where your property is
located is feet per year.
Local Permit Officer
The rate was established by careful analysis of aerial
photographs of the coastline taken over the past 50 years.
Studies also indicate that the shoreline could move as much as Address
feet landward in a major storm.
The flood waters in a major storm are predicted to be about
feet deep in this area. Locality
Preferred oceanfront protection measures are beach nourishment
and relocation of threatened structures. Hard erosion control
structures such as bulkheads,seawalls,revetments,groins,jetties Phone Number
and breakwaters are prohibited. Temporary sand baes may be
authorized under certain conditions.
The applicant must acknowledge this information and
requirements by signing this notice in the space below. Without
the proper si , e application will not be complete.
// 441 Z/
Property Owner Signature Date
RECEIVED
Revised May 2011C
APR 232021

U.S. DEPARTMENT OF HOMELAND SECURITY OMB No. 1660-0008
ederaLEmergency Management Agency Expiration Date: November 30, 2022
National Flood Insurance Program
ELEVATION CERTIFICATE
Important: Follow the instructions on pages 1-9.
Copy all pages of this Elevation Certificate and all attachments for(1)community official, (2)insurance agent/company, and(3)building owner.
SECTION A—PROPERTY INFORMATION FOR INSURANCE COMPANY USE
Al. Building Owner's Name Policy Number:
THOMAS MIX AND WIFE, KELLY MIX
A2. Building Street Address(including Apt., Unit, Suite, and/or Bldg. No.)or P.O. Route and Company NAIC Number:
Box No.
109 OLEANDER COURT
City State ZIP Code
SURF CITY North Carolina 28445
A3. Property Description (Lot and Block Numbers, Tax Parcel Number, Legal Description, etc.)
LOT 2, BLAND SHORES DRIVE
A4. Building Use(e.g., Residential, Non-Residential,Addition, Accessory, etc.) RESIDENTIAL
A5. Latitude/Longitude: Lat.34d23'46"N Long.77d35'32"W Horizontal Datum: ❑ NAD 1927 ❑x NAD 1983
A6. Attach at least 2 photographs of the building if the Certificate is being used to obtain flood insurance.
A7. Building Diagram Number 6
A8. For a building with a crawlspace or enclosure(s):
a) Square footage of crawlspace or enclosure(s) 843.00 sq ft
b) Number of permanent flood openings in the crawlspace or enclosure(s)within 1.0 foot above adjacent grade 5
c) Total net area of flood openings in A8.b 1000.00 sq in
d) Engineered flood openings? ❑x Yes ❑ No
A9. For a building with an attached garage:
a) Square footage of attached garage 0.00 sq ft
b) Number of permanent flood openings in the attached garage within 1.0 foot above adjacent grade 0
c) Total net area of flood openings in A9.b 0.00 sq in
d) Engineered flood openings? ❑ Yes ❑x No
SECTION B—FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
B1. NFIP Community Name&Community Number B2. County Name B3. State
TOWN OF SURF CITY 370186 PENDER COUNTY North Carolina
B4. Map/Panel B5. Suffix B6. FIRM Index B7. FIRM Panel B8. Flood B9. Base Flood Elevation(s)
Number Date Effective/ Zone(s) (Zone AO, use Base Flood Depth)
Revised Date
3720422300 J 12-06-2019 02-16-2007 AE 8.0
B10. Indicate the source of the Base Flood Elevation(BFE)data or base flood depth entered in Item B9:
❑ FIS Profile ❑x FIRM ❑ Community Determined ❑ Other/Source:
B11. Indicate elevation datum used for BFE in Item B9: ❑ NGVD 1929 ❑x NAVD 1988 ❑ Other/Source:
B12. Is the building located in a Coastal Barrier Resources System(CBRS)area or OtrArgEgiv,Cted Area(OPA)? ❑ Yes ❑x No
Designation Date: ❑ CBRS ❑ OPA �K(Ct vV�CUU
APR 2 3 2021 iaeL

ELEVATION CERTIFICATE OMB No. 1 Date: ob
Expiration November 30, 2022
IMPORTANT: In these spaces,copy the corresponding information from Section A. FOR INSURANCE COMPANY USE
Building Street Address(including Apt., Unit, Suite, and/or Bldg. No.)or P.O. Route and Box No. Policy Number:
109 OLEANDER COURT
City State ZIP Code Company NAIC Number
SURF CITY North Carolina 28445
SECTION C-BUILDING ELEVATION INFORMATION (SURVEY REQUIRED)
C1. Building elevations are based on: ❑x Construction Drawings* ❑ Building Under Construction* ❑ Finished Construction
*A new Elevation Certificate will be required when construction of the building is complete.
C2. Elevations-Zones A1-A30, AE, AH, A(with BFE), VE, V1-V30, V(with BFE),AR, AR/A, AR/AE,AR/A1-A30,AR/AH, AR/AO.
Complete Items C2.a-h below according to the building diagram specified in Item A7. In Puerto Rico only, enter meters.
Benchmark Utilized: NC CORS Vertical Datum: NAVD 1988
Indicate elevation datum used for the elevations in items a)through h)below.
❑ NGVD 1929 x❑ NAVD 1988 ❑ Other/Source:
Datum used for building elevations must be the same as that used for the BFE.
Check the measurement used.
a) Top of bottom floor(including basement, crawlspace, or enclosure floor) 4.5 ❑x feet ❑ meters
b) Top of the next higher floor 14.5 ❑x feet ❑ meters
c) Bottom of the lowest horizontal structural member(V Zones only) N/A ❑ feet ❑ meters
d) Attached garage(top of slab) N/A ❑ feet ❑ meters
e) Lowest elevation of machinery or equipment servicing the building feet(Describe type of equipment and location in Comments) 10.1 ❑ ❑ meters
f) Lowest adjacent(finished)grade next to building(LAG) 2.9 ❑x feet ❑ meters
g) Highest adjacent(finished)grade next to building(HAG) 3.2 ❑x feet ❑ meters
h) Lowest adjacent grade at lowest elevation of deck or stairs, including
structural support N/A ❑ feet ❑ meters
SECTION D-SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION
This certification is to be signed and sealed by a land surveyor, engineer, or architect authorized by law to certify elevation information.
1 certify that the information on this Certificate represents my best efforts to interpret the data available. I understand that any false
statement may be punishable by fine or imprisonment under 18 U.S. Code, Section 1001.
Were latitude and longitude in Section A provided by a licensed land surveyor? ❑x Yes ❑No ❑Check here if attachments.
Certifier's Name License Number �\````. CAii) ///
JAMES A. LEWIS L-4562 /%
0.. F -Ssio .1/2,
Title %
PROJECT MANAGER _ _ QUO 2 ' 7
�Company Name - • -
CHARLES F. RIGGS&ASSOCIATES, INC. - r
Address v
502 NEW BRIDGE STREET '` '..'.�..", 1-/P4- . -
4W1City State ZIP Code i i i' /
JACKSONVILLE North Carolina 28540 —
�//p/Zt
Signature/ Date Telephone Ext.
� ?4; //• //1/Z( [phone] 41
Copy all p es of this Elevation Ce i icate and all attachments for(/)community official, (2)insurance agent/company, and (3)building owner.
Comments(including type of equipment and location, per C2(e), if applicable)
DWELLING IS TWO STORY ON PILINGS, PARTIALLY ENCLOSED BELOW.
PRELIMINARY FLOOD MAPS SHOW A CHANGE IN FLOOD ZONE TO AE(10), SURVEYOR RECOMMENDS PLACING THE
BOTTOM OF MACHINERY AND ELECTRICAL EQUIPMENT SERVICING THE BUILDINGRECEIVErpHER.
APR 2 3 2021 (CFRA#20-10-08)

s• °ss. co. .
drG" °l' �'0,'O 7
0°�.4, 9s°ar A '11141 ��,opo other than the CAMA '
Perms. O,0'..„ °^ /� .� -sanitary waste
90 ds ` -„,„,,,...4_ Y Conservation,FIA
Lazard Estuarine Shoreline ORW Shoreline Public Trust Shc. �0O" b� 0 _ /'' % 7� •ay Connection,and
(For official use only) 0s'�p aar rd�� 0� ��
'rd . "co — A 0i.9t_O
:AL INFORMATION AGO c'0, ato
EC or a
)WNER bro
' 0� person
homas Mix and wife,Kelly Mix - ,L
O
109 Oleander Court am'
..
0
icay State roc Zip 28445 Phone [phone] °O"
as
[e-mail] dd, ��
A
)RIZED AGENT ~0°l OdrO X• y
Charles F.Riggs&Associates,Inc. 0. .�
P.O.Box 1570 NU e,. �00� +� y�
cksonville State NC Zip 28541 Phone [phone] I fun.
o�ri OGOr 20
[e-mail] (N o",p
O Bland S. °^h �' �" 20
(ION OF PROJECT:(Address,street name and/or directions to site.If not oceanfront,what is the name of the I !if \_\
109 Oleander Court,Surf City,Pender County(Parcel 4223-48-6157-0000) (2) Mr.James K
t waterbody.) Ss
(3) Lucky Dog Rea. G r'''''''"
d Two-Story tIPT1ON OF PROJECT:(List all proposed construction and land disturbance.) Proposed y 0(4) Q
ling on Pilings with Decks Over Concrete Slab Partially Enclosed below for Entry,Storage and Or
)F LOT/PARCEL: 9,404 square feet 0.216 - acresGarage with Proposed Pervious Drive ACKNOWLEDGEMEN1.
&Pool with Pool Decking&All Proposed Improvements Shown on Map I,the undersigned,acknowledk
)SED USE:Residential Q (Single-family E Multi-family D) Commercial/Industrial D Other ❑ may be susceptible to erosion ant
lar hazard problems associated with C)1�p
'LETS EITHER(1)OR(2)BELOW(Contact your Local Permit Officer if you are not sure which AEC applies tion and floodproofing techniques. �d
property): rq.
I furtherthore certify that I am authorized tt - ,taf,,
:EAN HAZARD AECs:TOTAL FLOOR AREA OF PROPOSED STRUCTURE:N/A square feet(includes the Local Permit Officer and their agents to e, -F• ' ,ation
3itioned living space,parking elevated above ground level,non-conditioned space elevated above ground level but related to this permit application. J
ng non-load-bearing attic space)
)ASTAL SHORELINE AECs:SIZE OF BUILDING FOOTPRINT AND OTHER IMPERVIOUS OR BUILT ad
SURFACES: 931 square feet(includes the area of the roof/drip line of all buildings,driveways,covered decks, r
to or masonry patios,etc.that are within the applicable AEC.Attach your calculations with the project drawing.)
Landowner or person authorized to act as his/her foil, ,it application
STORMWATER MANAGEMENT PERMIT:Is the project located in an area subject to a State Stormwater -.
ement Permit issued by the NC Division of Water Quality? This application includes:general information form).a sites Jibed on the hack of this application.the
NCI I ownership statement,the Ocean Hazard AEC Notice where necevs\\ .,for 5100.00 made payable to the locality.and
any information as may be provided orally by the applicant.The detar..,the application-as described by these sources are
list the total built upon area/impervious surface allowed for your lot or parcel:2,035 square feet. incorporated without reference in any permit which may be issued.Deviation from these details will constitute a violation of
any permit.Any person developing in an AEC without permit is subject to civil.criminal and administrative action.
RECEIVED
[PR 2 3 2021
DCM I `'LMINGTON C

OTHER PERMITS MAY BE REQUIRED:The activity you are planning may require permits other than the CAMA
Locality Permit Number minor development permit,including,but not limited to:Drinking Water Well,Septic Tank(or other sanitary waste
treatment system),Building,Electrical,Plumbing,Heating and Air Conditioning,Insulation and Energy Conservation,FIA
Ocean Hazard Estuarine Shoreline ORW Shoreline Public Trust Shoreline Other Certification,Sand Dune,Sediment Control,Subdivision Approval,Mobile Home Park Approval,Highway Connection,and
(For official use only) others.Check with your Local Permit Officer for more information.
GENERAL INFORMATION STATEMENT OF OWNERSHIP:
I,the undersigned,an applicant for a CAMA minor development permit,being either the owner of property in an AEC or a
LAND OWNER person authorized to act as an agent for purposes of applying for a CAMA minor development permit,certify that the person
Name Thomas Mix and wife,Kelly Mix listed as landowner on this application has a significant interest in the real property described therein.This interest can be
described as:(check one)
Address 109 Oleander Court _
CitySurf cay State NC Zipzea45 Phone [phone] Elan owner or record title,Title is vested in Fee Simple ,see Deed Book 4727
page 2700 in the Pender County Registry of Deeds.
Email [e-mail]
Elan owner by virtue of inheritance.Applicant is an heir to the estate of
AUTHORIZED AGENT probate was in County.
Name Charles F.Riggs&Associates,Inc. flf other interest,such as written contract or lease,explain below or use a separate sheet&attach to this application.
Address P.O.Box 1570
NOTIFICATION OF ADJACENT PROPERTY OWNERS:
City Jacksonville State NC Zip 28541 Phone [phone] I furthermore certify that the following persons are owners of properties adjoining this property.I affirm that I have given
ACTUAL NOTICE to each of them concerning my intent to develop this property and to apply for a CAMA permit.
Email [e-mail]
(Name) (Address)
(I) Bland Shores HOA,P O Box 2364,Surf City,NC 28445
LOCATION OF PROJECT:(Address,street name and/or directions to site.If not oceanfront,what is the name of the
adjacent waterbody.)109 Oleander Court,Surf City,Pender County(Parcel 4223-48-6157-0000) (2) Mr.James Malcolm Hall,III,P O Box 2706,Surf City,NC 28445
(3) Lucky Dog Real Estate,LLC,2507 Woodbine Road,Winston Salem,NC 27104
DESCRIPTION OF PROJECT:(List all proposed construction and land disturbance.) Proposed Two-Story (4)
Dwelling on Pilings with Decks Over Concrete Slab Partially Enclosed below for Entry,Storage and
SIZE OF LOT/PARCEL: 9,404 square feet 0.216 acresGarage with Proposed Pervious Drive ACKNOWLEDGEMENTS:
&Pool with Pool Decking&All Proposed Improvements Shown on Map I,the undersigned,acknowledge that the land owner is aware that the proposed development is planned for an area which
PROPOSED USE:Residential Q (Single-family Q Multi-family Q) Commercial/Industrial❑ Other ❑ may be susceptible to erosion and/or flooding.I acknowledge that the Local Permit Officer has explained to me the particu-
lar hazard problems associated with this lot.This explanation was accompanied by recommendations concerning stabiliza-
COMPLETE EITHER(1)OR(2)BELOW(Contact your Local Permit Officer if you are not sure which AEC applies tion and floodproofing techniques.
to your property):
OCEAN HAZARD AECs:TOTAL FLOOR AREA OF PROPOSED STRUCTURE:N/A I furthermore certify that I am authorized to grant,and do in fact grant,permission to Division of Coastal Management staff,
(1) square feet(includes the Local Permit Officer and their agents to enter on the aforementioned lands in connection with evaluating information
air conditioned living space,parking elevated above ground level,non-conditioned space elevated above ground level but related to this permit application.
excluding non-load-bearing attic space) /J •/
(2) COASTAL SHORELINE AECs:SIZE OF BUILDING FOOTPRINT AND OTHER IMPERVIOUS OR BUILT This the `°rR day of t'",20
UPON SURFACES: 931 square feet(includes the area of the roof/drip line of all buildings,driveways,covered decks,
concrete or masonry patios,etc.that are within the applicable AEC.Attach your calculations with the project drawing.) Landowner or person authorized to act as his/her•:j forit • f filing a CAMA permit application
STATE STORMWATER MANAGEMENT PERMIT:Is the project located in an area subject to a State Stormwater
Management Permit issued by the NC Division of Water Quality? This application includes:general information form),a site drawing as described on the back of this application,the
YES i � Nd ownership statement,the Ocean Hazard AEC otice where necessary,a check for$100.00 made payable to the locality,and
2,035 any information as may be provided orally by the applicant.The details of the application as described by these sources are
If yes,list the total built upon area/impervious surface allowed for your lot or parcel: square feet. incorporated without reference in permit which maybe issued.Deviation pany from these details will constitute a violation of
any permit.Any person developing in an AEC without permit is subject to civil,criminal and administrative action.
RECEIVED
4 pR 2 3 2021
DCM W!LMINGTnnr �r`

U.S. Postal Service'"' U.S. Postal Service-
CERTIFIED MAIL® RECEIPT CERTIFIED MAIL® RECEIPT
ft1 Domestic Mail Only fn Q. Domestic Mail Only
.0 For delivery information,visit our website at www.Lisps.coin . Q-
r*+ ,• �. •r ,rI .A For delivery information,visit our website at www.usps.com
if in
L. USE Halo ' '' L USE
Certified Mail Fee 60
rM1r1 $ 0600 certified Mall Fee $3.60 0600
Si .R5 06 $
Extra SeMcea&Fees(otreckbor add fee *E7_RrY 06
Q 0 Return Receipt(nerdcopy) $ r ''' Extra Services&Fees(dredcbo.add fee at
O ❑Retum Receipt(electronic) $ $C7.U0 Postmark-- Q ❑Return Receipt(hardcopy) $ V ,J! -
CI
❑certified Meg Restricted Delivery $ S 0_an Here p 0 Return Receipt(electronic) $ $0,0U
p ❑Adult Signature Required $ ,,:�CIO 0 ['certified Mau Restricted Delivery $ 10-00 Postmark
['Adult Signature Resulted $ Here
❑Adult signature Restricted Delivery$ o ❑ $i t.00
❑Adult signature Restricted Delivery$
O Postage $0.75
mO Postage 7�
Total Postage and 04/21/2021 m $ $0'`_n
o :20 o Total PostageandF� 04/21/2021
$ $
/ ��,
r' Sent Tok. u
CIr� u t` 0 Sent To m( 'Ti l � 1 l (� .-�E
Street Apt.No., o rOo _ ,_ \► r� -11,L-
*OL7�� f„ v, 1 I'V2 0 C Street andApt No.,orT O Erai fir;
City State,ZIP+ �-C �"V�l
` 1 Ks s .l�»� tieia fIPt441-5
ur ' . 6��C
PS Form 3800,April 2015 PSN 7530-02-000-9047 See Rev"rse for Instructions
PS Form 3800,April 2015 PSN 7530-02-000-9047 See Reverse for Instructions
U.S. Postal ServiceT"
CERTIFIED MAIL° RECEIPT
Ln Domestic Mail Only
IT"
.D For delivery information,visit our website at www.usps.com
.=' Certified Mail Fee $3.60
r` $ 0600
m Extra Services&Fees(check bo, add ke $? ..rt 06
O ❑RetumReceipt(hardcopy) $ rJ..!r '
❑Return Receipt(electronic) $ $1_I,Ulf Postmark
p ❑certified Mau Restricted Delivery $ $0.00 Here
C) ❑Adult Signature Required $ $i).00
['Adult signelrrs Restricted Delivery$
Cl Postage
m Lf) $ 'b0.75
Totes Postage an 04/21/20 1
't.2+1
N Sent To 1..
la f ha v
O Street andApt.No.,or hb box k7, B b
rrU� Ya.3 `fL
CH,Slate,ZIP+4a l
cgset_L
SKr �i� N�
PS Form 3800,April 2015 PSN 7530-02-000-9047
See Reverse for Instructions

Date Date Check From Name of Vendor Check Check Permit Rct.
Received Deposited Permit Holder Number amount Number/Comments
4/27/2021 Charles F. Riggs Thomas and Kelly First 16882 $100.00 minor permit fee, 109 Oleander JD rct.
and Associates Inc. Mix Citizens Ct, Surf City PNCO 13411
Bank