86501A_Kellum, Randy_20220422

3&ICWr4,xOCAMA ❑ DREDGE & FILL N9 86501 B C D
a Previous permit
GENERAL 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 ❑ Rules attached. ❑ General Permit Rules available at the following link: www.dgq.nc.g_ov/CAMArules
Applicant Name _
Address
City
Phone # (_ )
Email
State ZIP
Authorized Agent
Project Location (County):
Street Address/State Road/Lot #(s)
Subdivision
City
Affected ❑ CW ❑ EW ❑ PTA ❑ ES ❑ PTS Adj. Wtr. Body (nat/man/unk)
AEC(s): ❑ OEA ❑ IHA ❑ UW ❑ SPIMA ❑ PWS Closest Maj. Wtr. Body
ORW: yes/no PNA: yes/no
Type of Project/ Activity
Shoreline Length
Access Length
Pier (dock) length
Fixed Platform(s)
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
Site Photos: yes nQ
Riparian Waiver Attached: yes �171
A building permit/zoning permit may be required by:
Permit Conditions
(Scale: )
14.
❑ 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 Permit Officer's PRINTED Name
Signature "Please read compliance statement on back of permit" Signature
Application Fee(s) Check #/Money Order Issuing Date Expiration Date

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
2� e\lP,r aart fb,C- C. WG
Mailing Address of Owner: 1 ) n <✓ V e- C G c- e ev, �) c 14,- c ► Foci L)r^_
Owner's email: Acc v 7 n o , I ec ,!� Owner's Phone#:
Agent's Name: G `' t �c" ` h ��� 1 Agent Phone#:
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
description or drawing with dimensions must be provided with this letter.
J/ 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 401 S. Griffin St., Ste. 300, Elizabeth City, NC, 27909. 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
-OR-
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:
2. Sit
ARPO's Phone#: .3 3 1 ,5 ► G
Date: H - Z n - Z Z "waiver is valid for up to one year from ARPO's Signature'
Revised July 2021

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 delivery of notice) are needed.
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 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.
Who/What 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: https://www.sosnc.gov/search/index/corp. 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.
Revised July 2021

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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: W rit,4
Address of Property: 1 Z O � �r (� rr�:., �r `-�1�� 1 Fo(`rJ, is G
Mailing Address of Owner: I Zd 'e U e,r Gr­co �c � -tS-_0r-` NG
Owner's email:Acceti�Sema,),e,Owner's Phone#: 2,52"53�,-576_7
Agent's Name: Agent Phone#:
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
description or drawing, with dimensions, must be provided with this letter.
_ V 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 401 S. Griffin St., Ste. 300, Elizabeth City, NC, 27909. 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.)
wish to waive some/all of the 15' setback
-OR-
of Adjacent Riparian Property Owner
I do not wish to*owaive the 15' setback requirement (initial the blank) f' <
Signature of Adjacent Riparian Property Owner l
Typed/Printed name of ARPO:
Mailing Address of ARPO: (�[/� ��+ ��t�-CX'l/t`n
ARPO's email: ce, ARPO's Phone#:�54 3--5q " j5
Date: " t � 40 - Z L *waiver is valid for up to one year from ARPO's Signature"
Revised July 2021

e
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 delivery of notice) are needed.
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 an opportunity to consider these comments/objections before a permit decision is made.
"Permission" of adiacent 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.
Who/What 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: https://www.sosnc.gov/search/index/corp. 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.
Revised July 2021

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