86500A - Cisewski, Jeffrey

®CAMA ❑ DREDGE & FILL
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GENERAL PERMIT Previous permit
K New ❑ Modification ❑ Complete Reissue ❑ Partial Reissue Date previous pemnit issued
As authorized by the State of North Carolina, Department of Environmental Quality and the Coastal Resources Commission In an area of concern pursuant to:
I SA NCAC 7 y 1 ` 1 ;? co ❑ Rules attached. ® General Permit Rules ayailable at the following linic www.dm.rw_ 2%&6 lArules
Applicant Name a i` Cf i4 C
Address Ina m,,►ps f"\Gb�i1P
City it' state V a zip
Phone #
Email t C L SE41-sr-1 @ Cox, hRX
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Authorized Agerrt�ais-ld ! f �{rnhc ,It.�t�
Project Location (County): - pet hy-
Street Address/State Road/Lot #(s) '#30
C�.
Subdivision 'C;rA•4.1N V ` _P�Serw
city t4 emy., 4y c zip 271t7
Affected Elcw O Ew W PTA ® Es &PTS Adi. wo, Body f oLr to Ja Ea unk)
AEC(s): ❑ OEA ❑ IHA ❑ UW []SPIMIA ❑ PWS Clot Mal. wtr: Body /'+ ` Le
ORW: ye;/fi3 j PNA: yes/ f5
Type of Project/ Activity C4 ShUAI M 5r x $(S' ge, uY `7"
it, (xZo; C GA..AjCo`)ct w 2 5
Shoreline Length_11
Access Len Q• _ _i _ J_ ! ... �_ _ 1..Q.r� _ z�'+I �I--tr-1r-Ir --y� _i� i-
Pier (dock) length Bw x 5
Fixed Platforms 33.3` A IZr+ •-'-.f _`-�-� u-?--'-- > _: �7 '
1 ! ZOr
f I 1 I I 1 I t I
Floating Platform(s)�__'
t
t+ Y ..1 . r W �..- r- •r-T -,-r t-+- I
Finger pier(s)
Total Platform areaa
Groin length/#
Bulkhead/ Riprdp length •.,
_ !.-_ �. _
1ik"1 1
Avg distance offshore
1
71
r
Breakwater/Sill
_
Max distance/ length
Basin, channel
Cubic yards
, !-}
, - _4- -/ 1 _.r__ __1 , r
-• -r-d
Boat ramp
Boathouset 16, k (Zf r 1 1 1
Beach Bulldozing
Other
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SAVobserved: yes
'
Moratorium: yes r
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Site Photos: ��gg no =-+ I +-i-�--� __L _._+...._
LLj I t -" i t ...._� _� �t
Riparian Waiver Attached: yes no �� _ _�_� _ s__ �_ _ _i _
A building permit/zoning permit may be required by -
Permit Conditions
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❑ TAR/PAWNEUSE/BUFFER (drde 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 APPLYTO THIS PROJECT AND REVIEWED COMPLIANCE STATEMENT. (Please Initial)
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Agent or pli PRI ame Permit Offs rj PRINTED Name
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Signatur 'Please read compliance statement on back of permit" Signature
aka, °_0 Soaig 7-2z/22. 10 42 /aa
Application Fee(s) Check #/Money Order Issuing Date Expiration Date

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: —W ar. L.aWrA + Z5e
Mailing Address: 1a2 W45 Aa�JoAe-
Phone Number:
Email Address: Ci SQu.?5{rri PCOI>1Gf
I certify that 1 have authorized,n' iA,, Pal Q /+�(tG C`_on-# c r %J ►2�t >` 11 t`qa oi
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: let P.,,r' CC?1f�°fEGf A�Q
at my property located at
inC- County.
I furthermore certify that I 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
Laura Cisewski
Print or Type Name
Trtle
Dec 27, 2021
Date
This certification is valid through

N.G. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
CERTIFIED MAIL • RETURN RECEIPT REQUESTED g[ HAND DELIVERY
(Top portionto be completed by owner or their agent)
Name of Property Owner:-Jle-P� alA l
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Address of Property: j_� tyq-soie-'c..k1C-' k4eY H; fH
Mailing Address of Owner. t0Z M i' le
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Owner's email: t6.(vLd5Lc2A v1e{ Owner's Phan
Agents Name: �) 'Nil aa/t %iAgent
Agent's Email: aeQ Y16re _ ,Nl a �� n� idma ; c
ADJACENT RIPARIAN PROPERTY OWNI
(,Bo„�ottm000rtion to be completed by the Ad
I hereby certify that I own property adjacent to the above referent
permit has described to me, as shown on the attached drawin
description or grawinq, with dimensions, must be provided with
I DO NOT have objections to this proposal. I
ff you have objections to what Is being proposed, you m
Management (DCM) In writing within 10 days of receipt of I
mailed to 401 S. Griffin St., Ste. 300, Elizabeth City, NC, 27
contacted at (252) 2643901, No response Is considered the
notified by Certified Mail.
WAIVER SECTION
I understand that any proposed pier, dock, mooring pilings, boat
groin must be set back a minimum distance of 15' from my area
(this does not apply to bulkheads or dprap revetments). (if you v
the appropriate blank below.)
I DO wish to waive soma/all of the 15' setback
-0R-
Signature ofRc Jecent F
I do not wish to waive the 15' setback requirement pnnIai the
Signature of Adjacent Riparian Property Owner:
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Typed/Printed name of A RPO: t•►P Csol CJU rse Mu r k am
Mailing Address of ARPO: Ioij 5co�rm Ha
ARPO's email:
ARPO's Phone#:
"waiver is valid for up to one year from ARPO's Signature"
Revised May 2021
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N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
CERTIFIED MAIL •• RETURN RECEIPT REQUEST. Q or HAND DELIVERY
(Top portion to be Completed by owner or their agent)
Name of Property Owner
Addrwm of Property:
0-"\d LA�r�
Mailing Address of Owner. tCTL HaVWe- t �G rho
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Owners email: 0 C0� Owner's Phonel,
Agent's Name:,A�IQnY-Ae Agent P
►�tci i,'1e- CQrt fi'0CV 7
Agent's Email:
ADJACENT RIPARIAN PROPERTY OWNEF
(Qottgm portion to be comRiod by the Adia
I hereby certify that I own property adjeoentto the above refsronoa
permit has described to me, as shown on the attached drawing,
description or drawtnn with dimensions must be provided wilt th
I DO NOT have objections to this proposal. i C
if you have objections to what Is being proposed, you mu
Management (DCM) In writing w1th1n 10 daya of reavlpt of th
mailed to 401 S. Grfffin St, Ste. 300, Elizabeth City, NC, 279
contacted at [phone], No response Is considered the a `
notified by Certified Alell.
WAIVER SECTION
I understand that any proposed pier, dock, mooring pilings, boat i
groin must be set back a minimum distance of 15' from my area c
(this does not apply to bulkheads or riprep revetments). (If you wi
the appropriate blank below.)
100 wish to waive some/all of the I5'setback
Signature ofAcUmntRi
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I do not wish to waive the 15' setback requirement (initial the btai
Signature of Adjacent Riparian Property Owner.
Typed/Printed name of ARPO: _ na `rl� ►�
Mailing Address of ARPO: J 1'-0 IAI E44U0 C� (�° 10 C1, V-
ARPO's email:
ARPO's Phone#.
Dab: "waiver is valid for up to one year from ARPO's Signature"
Revised May 2021

N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTiFICATIONIWAIVER FORM
CERTIFIED MAIL RETURN RECEIPT REQUESTED or HAND DELIVERY
(Top portion to be Completed by owner or their agent)
Name of Property Owner. J e 4 an. i'1 U (CA (1- t 5p i A )�
Address of Property: I
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MailingAddress ofOwner
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Owner's emall: ►\6 _ Owner's Phone#:
Agent's Name:. ((,'aa' Agent Phone*
1.1 C.cun 1`roO
Agent's Email: O� PCX S& c-VM`f0(-t-'5 5c) !M
ADJACENT RIPARIAN PROPERTY OWNE
(Bottom portion to be completed by the Adis
I hereby certify that I own property adjaoent to the above roforonoc
permit has described to me, as shown on the attached drawing
description or drawing with dimensions must be provided with ni
100 NOT have objections to this proposal I I
If you have objections to what is being proposed, you mu
Management (DCM) In writing within 10 days of r000lpt of ti
mailed to 401 S. GrJflin St, Ste. 300, Elizabeth City, NC, 271
contacted at [phone]. No response /s considered the
notified by Certified M411.
WAIVER SECTION
I understand that any proposed pier, dock, mooring pilings, boat
groin must be set back a minimum distance of 15' from my area c
(this does not apply to bulkheads or rlprep revetments). (if you wi
the appropriate blank below.)
100 wish to waive some/ail of the 1 S' setback
Signature ofAc#scentRi
M
I do not wish to waive the IS, setback requirement (initial the blai
Signature of Adjacent RJpadan Property Owner.
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Typed/Printed name of ARPO: N) e CO L' (( ✓a A- 4
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Mailing Address of ARPO: _3}J �� [,�-�P (I 5 i C- 3p0 �u 0a M -AJ(— ; � a1J -4O
ARPO's email:
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ARPO's Phone;:
'waiver Is valid for up to one year from ARPO's Signature"
Revised May 2021
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