Theodorakis, Greg 84729C

'aOF WAST41 LN c❑CAMA ❑ DREDGE & FILL N9 84729 A B C
y = GENERAL PERMIT Previous permit
Date previous permit issued
New ❑ Modification [—]Complete Reissue ❑ Partial Reissue
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 '' i " ❑ Rules attached. ❑ General Permit Rules available at the following link: www.deq.nc.goy/CAMAruIes
Applicant Name
Address
City State
Phone # (_ )
Email
Affected ❑ CW ❑ EW ❑ PTA
AEC(s): ❑ OEA ❑ IHA ❑ UW
ORW: yes/no PNA: yes/no
Authorized Agent
Project Location (County):
ZIP Street Address/State Road/Lot #(s)
❑ ES ❑ PTS
❑ SPIMA ❑ PWS
Subdivision
City
Adj. Wtr. Body
Closest Maj. Wtr. Body
nat/man/unk)
Type of Project/ Activity
(Scale.` �..
Shoreline Length
I
Access Length
_W _. _ ...
Pier (dock) length7 r
FixedPlatform(s) [IT
. ; ....M ...
Floating Platform(s)
Finger pier(s)
Total Platform area
Groin length/#
Bulkhead/ Riprap length
Avg distance offshore
Breakwater/Sill
Max distance/ length
Basin, channel
Cubic yards
Boat ramp
Boathouse/ Boatlift
Beach Bulldozing
Other
SAV observed: yes no
Moratorium: n/a yes no r
Site Photos: yes no
Riparian Waiver Attached: yes no
A building permit/zoning permit may be required by:
Permit Conditions
❑ TAR/PAM/NEUSE/BUFFER (circle one)
�, ❑ See note on back regarding River Basin rules
— ❑ See additional notes/conditions on back
I AM AWARE OF STATUTES, CRC RULES AND CONDITIONS THAT APPLY TO THIS PROJECT AND REVIEWED COMPLIANCE STATEMENT.
Agent or Applicant PRINTED Name Permit Officer's PRINTED Name
(Please Initial)
Signature "Please read compliance statement on back of permit" Signature
Application Fee(s) Check #/Money Order Issuing Date Expiration Date

o1°Ft°"""1 ❑CAMA ❑ DREDGE & FILL N© 84729 A B C D
y 004
GENERAL PERMIT Previous permit
Date previous permit issued
New ❑ Modification ❑ Complete Reissue ❑ Partial Reissue
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 + ❑ Rules attached. ❑ General Permit Rules available at the following link: www.deq.nc.gov/CAMArules
Applicant Name _
Address
City
Phone # (_
Email
State ZIP
Affected ❑ CW ❑ EW ❑ PTA
AEC(s): ❑ OEA ❑ IHA ❑ UW
ORW: yes/no PNA: yes/no
Type of Project/ Activity
Shoreline Length
Access Length
Pier (dock) length
Fixed Platform(s)
Floating Platform(s)
Total Platform area
Groin length/#
Bulkhead/ Riprap length
Avg distance offshore—
Breakwater/Sill
Max distance/ length
Basin, channel
Cubic yards
Boat ramp
Boathouse/ Boatlift
Beach Bulldozing
Other
Authorized Agent
Project Location (County):
Street Address/State Road/Lot #(s)
Subdivision
City
❑ ES ❑ PTS Adj. Wtr. Body
❑ SPIMA ❑ PWS Closest Maj. Wtr. Body
SAV observed: yes no -
Moratorium: n/a yes no tf
Site Photos: yes no -- —�- E -
Riparian Waiver Attached: yes no i I
A building permit/zoning permit b d b
Permit Conditions'
(Sca
TT
may a require y. 94, ❑ TAR/PAM/NEUSE/BUFFER (circle one)
❑ See note on back regarding River Basin rules
❑ See additional notes/conditions on back
I AM AWARE OF STATUTES, CRC RULES AND CONDITIONS THAT APPLY TO THIS PROJECT AND REVIEWED COMPLIANCE STATEMENT. (Please Initial)
Agent or Applicant PRINTED Name
Signature "Please read compliance statement on back of permit"
Application Feels) Check #/Money Order
Permit Officer's PRINTED Name
Sig natur ,
9 - , It h
Issuing Date Ex i •atom Date

N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
CERTIFIE&MAIL • RETURN RECEIPT REQUESTED or HAND DELIVERY
portion to be completed by owner or their agent)
Name of Property Owner: ( )-1'�� f h -G-o A 0 �-A
iS
Address of Property: i t-I� I� I) S `� VV D ��LA"!� T(C I?V,' A. ]
Mailing Address of Owner: -3 3i 3 ('��rsL 1 a C i�� � ��(-Z IFS 6
Owner's email:%e(4,,ssAk)(-e4av--, Owner's Phone#:
Agent's Name: Agent Phone#:
Agent's Email:
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom portion to be completed by the Adlacent Property Owner)
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
descript
ion or drawinct with dimensions must be provided with this letter.
/✓ I DO NOT have objections to this proposal. I DO have objections to this proposal.
If you have objections to what is being proposed, you must notify the N.C. Division of Coastal
Management (DCM) in writing within 10 days of receipt of this notice. Correspondence should be
mailed to 400 Commerce Ave., Morehead City, NC 28557. DCM representatives can also be contacted
at [phone]. No response is considered the same as no objection if you have been notified by
Certified Mail
WAIVER SECTION
I understand that any proposed 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
(this does not apply to bulkheads or riprap revetments). (If you wish to waive the setback, you must sign
the appropriate blank below.)
I DO wish to waive some/M-of the 15' setback k
Signature of Adjacen iparian Property Owner
-OR-
I do not wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner: &�to-��
Typed/Printed name of ARPO:
Mailing Address of ARPO: L 7 NO(V T V A S 14� V ge 1
ARPO's email: d4tticA41; � cl c- �rter: �tc�T ARPO's Phone#: (6991
Date: 10 �.q-D 4X X 1 *waiver is valid for up to one year from ARPO's Signat CEIVED
Revised May 2021
JAN ] 0 2022
DCM-MHD CITY

N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
CERTIFIED MAIL - RETURN RECEIPT REQUESTED or HAND DELIVERY
(Top portion to be completed by owner or their agent)
Name of Property Owner: (s— V e-
Address of Property: (F 0 L i--)
Mailing Address of Owner: it— 2, e,
Owner's email: A:i35',F hCe,C LUA,)PZ—Owner's Phone#: g� -3
Agent's Name: Agent Phone#:
.5 km z IT'S fa v ✓ �..
Agent's Email:
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom portion to be completed by the Adjacent Property Owner)
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
I DO NOT have objections to this proposal. I DO have objections to this proposal.
If you have objections to what is being proposed, you must notify the N.C. Division of Coastal
Management (DCM) in writing within 10 days of receipt of this notice. Correspondence should be
mailed to 400 Commerce Ave., Morehead City, NC 28557. DCM representatives can also be contacted
at [phone]. No response is considered the same as no objection if you have been notified by
Certified Mail.
WAIVER SECTION
I understand that any proposed 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
(this does not apply to bulkheads or riprap revetments). (If you wish to waive the setback, you must sign n
the appropriate blank below.) No W o►I'v tj w , {�, ; � �'� � � � rt l '1 ssrt o Vr 04 Ip v� k�rtaJ�
Acc4cr -15q+ a s*-f back,
I DO wish to waive some II of the 15' setb - '��
,. _...
Signature of Adjacent Riparian roperty Owner r�UM
Lem
I do not wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner
Typed/Printed name of ARPO: fop
" 1N (s
Mailing Address ofARPO: aka® LOU C %arr wo- P11T fl d.4;4
C4f,+a.'n b ;10 w;11,'R Msea
ARPO's email: (a ARPO's Phone#::. S 2— 2.3 0' 5 3 IS
Date: J11 IAO *waiver is valid for up to one year from ARPO's Signature*
R
Revised May 2Sr%m F--
JAN 10 2022
DCM-MHD CITY

N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
CERTIFIED MAIL - RETURN RECEIPT REQUESTED or HAND DELIVERY
(Top portion to be completed by owner or their agent)
Name of Property Owner:
Address of Property: _
Mailing Address of Owner:
Owner's email:
Agent's dame:
Agent's Email:
Owner's Phone#:
Agent Phone#:
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom portion to be completed by the Adjacent Property Owner)
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 DO NOT have objections to this proposal. I DO have objections to this proposal.
If you have objections to what is being proposed, you must notify the N.C. Division of Coastal
Management (DCM) in writing within 10 days of receipt of this notice. Correspondence should be
mailed to 400 Commerce Ave., Morehead City, NC 28557. DCM representatives can also be contacted
at [phone]. No response is considered the same as no objection if you have been notified by
Certified Mail.
WAIVER SECTION
I understand that any proposed 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
(this does not apply to bulkheads or riprap revetments). (If you wish to waive the setback, you must sign
the appropriate blank below.)
I DO wish to waive some/all of the 15' setback
Signature of Adjacent Riparian Property Owner
I do not wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner:
Typed/Printed name of ARPO:
Mailing Address of ARPO:
ARPO's email:
ARPO's Phone#:
Date: *waiver is valid for up to one year frorn ARPO's Signature*
RECEIVED
Revised May 2021
JAN 10 2022

TIPS FOR ADJACENT RIPARIAN OWNER NOTIFICATION & WAIVER FORMS
CAMA Regulations require notice of proposed development to the Adjacent Riparian Property Owners (15A
NCAC 7J.0204(b)(5)). Proof of actual notice (a sign -off by the owner on this form) or certified mail return
receipts (showing deliveryof notice) are needed, or any other method which satisfies the Local Permit Officer
(LPO) that a good faith effort has been made to provide notice.
The purpose of this notice is to make adjacent riparian property owners aware of the proposed development
so that they have an opportunity to provide comments (or potentially object to) the proposed development,
and to give DCM or the LPO an opportunity to consider these comments/objections before a permit decision
is made. "Permission" of adjacent property owners is not necessarily required for DCM to issue a permit;
however, permission must be obtained for certain types of proposed developments if they fall within a 15'
setback area along the riparian access area of the adjacent property, as determined solely by DCM. It is in
the applicant's best interest to provide comprehensive and accurate notice so that any concerns or objections
can be resolved early in the permit review process. In addition, if the adjacent riparian property owner appeals
the permit decision, insufficient notice could be a basis for granting such an appeal.
Who is an Adjacent Riparian Property Owner?
What is Adjacent? (Note: DCM reads this broadly to ensure comment by potentially impacted neighbors)
• A property that shares a boundary line with the site of proposed development; AND
• A property that fronts a natural or manmade waterbody that is connected to coastal waters and
can support some form of navigation, even a kayak or canoe, including a common canal system
or a manmade basin.
• Easement holders? Yes, if the easement could be impacted by the proposed development.
• Streets/Roads? Only if the street/road could be impacted by the proposed development. This
might include street -ends which might be used for parking and beach access.
• Holders of recognized submerged lands claims/shellfish franchises.
What is Riparian?
Do the boundaries of the adjacent property legally intersect with the water at mean high tide? If there is a
question about whether an adjacent property is considered "riparian," please reach out to DCM Staff -
especially on the oceanfront beach where there may be undeveloped parcels on the beach or in the water.
WhoiWhat is a Property Owner?
For private individuals (or families), send notice to the address listed on the tax card. If the property is owned
by an Inc. or LLC, please send notice to the person listed as the registered agent on the NC Secretary of
State's Corporations Look Up site: nett For Condominiums or
neighborhoods with an owners' association (HOA/POA), send notice to the association (which is usually a
corporation, for which you send notice to its registered agent).
What is Notice, and how do I ensure it is received?
• You can meet with your adjacent property owner, provide a description or drawing of the
proposed development, and ask them to sign this form and return it to DCM; OR
• You can hand -deliver this form and a description or drawing, and ask your neighbor to return it to
DCM (consider providing them with a stamped envelope); OR
• You can mail this form by USPS Certified Mail, return receipt requested (the Green Card). If you
choose this option, you must provide either the signed & returned green card OR track the
certified mail package number on USPS.GOV's online tracking system, and provide the tracking
print-out as proof of delivery to DCM
If you have any questions about this process, please reach out to DCM Staff and DCM Legal Counsel
and we will work to answer your questions.
"f FCEIVE®
Revised May 2021
JAN 10 2022
DCM-MHD CITY

RECEIVED
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