84635C - Lisker, Kelly

y�°F`°"�'^� T❑CAMA ❑ DREDGE & FILL 84635 A B C D
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:
I SA NCAC ❑ Rules attached. ❑ General Permit Rules available at the following link: www.deq.nc.gov/CAMArules
Applicant Name Authorized Agent
Address Project Location (County):
City State ZIP Street Address/State Road/Lot #(s)
Phone # ( )
Email
Affected ❑ CW
AEC(s): ❑ OEA
ORW: yes/no
❑EW ❑PTA
❑ IHA ❑ UW
PNA: yes/no
Type of Project/ Activity
Shoreline Length
Access Length
Pier (dock) length
Fixed Platform(s) 1
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 s
SAV observed:
yes nc
Moratorium: n/a
yes nc
Site Photos:
yes nc
Riparian Waiver Attached:
yes nc
A building permit/zoning permit may be
Permit Conditions
❑ ES ❑ PTS
❑ SPIMA ❑ PWS
Subdivision
City ZIP
Adj. Wtr. Body (nat/man/unk)
Closest Maj. Wtr. Body
(Scale 1<`r)
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❑ 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 Feels) Check #/Money Order Issuing Date
Expiration Date

1o1CO�r� 6❑CAMA ❑ DREDGE & FILL 9 84635 A B C D
0
Previous permit
y = 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.deq.nc.gov/CAMArules
Applicant Name _
Address
City
Phone # (_ )
Email
Authorized Agent
Project Location (County):
State ZIP Street Address/State Road/Lot #(s)
Subdivision
City
P
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 no
Riparian Waiver Attached:
yes no
A building permit/zoning permit may be r
Permit Conditions
(Scale:' )
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"
Application Fee(s) Check #/Money Order
Signature
Issuing Date Expiration Date

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: L-15irce-
Mailing Address:
14
Phone Number:
Email Address:
I certify that I have authorized e,,,94 o4j,,
f ( Agent I Contractor .
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
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at my property located ate rA A uc-
in (, Eju ) c,,,- 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:
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Prt or Type Name
Title
Date
This certification is valid through � I ) 3 1 -o3

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:
Address of Property:
'a� ,ks
Mailing Address of Owner:
Owner's email: t i ► $ i(rne
Agent's Name: %
Agent Phone#:
Agent's Email: jVv-Ji! t4 Q
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom portion to be completed by the Adjacent Property Owner)
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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 set ack, you must sign
the appropriate blank below.)
I DO wish to waive some/all of the 15' setbackA
Signature of Adjacent Riparian
-OR-
I do not wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner`' "•- - t N—I
JIL,
Typed/Printed name of ARPO:_ ip. C1G r'' J
Mailing Address of ARPO: zI 7 2 kCaGv-�e- rz R&=
ARPO's email: ARPO's Phone#: a -�
. ,
Date: rt7 *waiver is valid for up to one year from ARPO's Signature*
Revised July 2021