87619D-DEROSA

0cour#, ❑CAMA ❑ DREDGE & FILL 1 a� �1� N� 87619 A B c o
/ �' Previous permit
GENERAL PERMIT C (�-� ��
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 0 C)
❑ Rules attached.
❑ General Permit Rules available at the following link: www.dp%nc.Qov/CAMArules
Applicant Name
..
C
Authorized Agent ,.� t
Address :' I` i
Project Location (County):
City bti • Ij t '. C i i - State
zip `�r J (i
Street Address/State Road/Lot #(s) UAJ�ti
c f c • (�
Phone # (_)
Email = Y I I �fi '� ej
Subdivision
C/t�
City < t_ <- i/1 ZIP
Affected ❑ CW ❑ EW ❑ PTA
❑ ES ❑ PTS
Adj. Wtr. Bodynk
AEC(s): ❑ OEA ❑ IHA ❑ UW
❑ SPIMA ❑ PWS
Closest Maj. Wtr. Body
ORW: yes/no PNA: yes/no
Type of Project/ Activity
i
(Scale: i�)
Shoreline Length
Access Length1
Pier (dock) length hl
Fixed Platform(s) IC X/ 0
Floating Platform(s) Ixt (Q
Finger pier(s)
Total Platform area �> y
Groin length/#
Bulkhead/ Riprap length
Avg distance offshore
Breakwater/Sill
Max distance/ length
Basin, channel
Cubic yards
Boat ramp
Boathous,J-Boatli /' L f Z.
Beach Bulldozing
Other rw4 !o
1 0 ]it / 2..
SAV observed: yes no .
Moratorium: n/a yes no
Site Photos: yes no:
Riparian Waiver Attached: yes no
........A.1Li.1. i
A building permit/zoning permit may required by: rnYi < L a c
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- (Please Initial)
Agent or Applicant PRINTED Name Permit Offic�R,INTED Name
Signature **Please read compliance statement on back of permit** Signature
Application Fee(s) Check #/Money Order Issuing Date Expiration Date

Statement of Compliance and Consistency
This permit is subject to compliance with this application and permit conditions. Any violation of these terms may
subject the permittee to a fine or criminal or civil action; and may cause the permit to become null and void.
This permit must be on the project site and accessible to the permit officer when the project is inspected for
compliance. The applicant certifies by signing this permit that: 1) prior to undertaking any activities authorized by this
permit, the applicant will confer with appropriate local authorities to confirm that this project is consistent with the
local land use plan and all local ordinances, and 2) a written statement from the adjacent riparian property owner(s)
has been obtained, or proof of delivery of certified mail notification of the adjacent riparian property owner(s).
The State of North Carolina and the Division of Coastal Management, in issuing this permit under the best available
information and belief, certify that this project is consistent with the North Carolina Coastal Management Program.
River Basin Rules Applicable To Your Project:
F1Tar - Pamlico River Basin Buffer Rules 1-1 Neuse River Basin Buffer Rules
If indicated on front of permit, your project is subject to the Environmental Management Commission's Buffer Rules
for the River Basin checked above due to its location within that River Basin. These buffer rules are enforced by the
NC Division of Water Resources. If you have any questions, please contact the Division of Water Resources at the
Washington Regional Office (252-946-6481) or the Wilmington Regional Office (910-796-7215).
Notes/Additional Permit Conditions:
Please ensure all debris associated with the removal or construction of the permitted development is contained within the authorized
project area and disposed of in an appropriate upland location.
Division of Coastal Management Offices
Morehead City Headquarters
400 Commerce Ave Morehead City, NC 28557
252-808-2808/ 1-888-4RCOAST Fax: [phone]
(Serves: Carteret, Craven — south of the Neuse River, Onslow
Counties)
Elizabeth City District
401 S. Griffin St. Ste. 300
Elizabeth City, NC 27909
252-264-3901
(Serves: Bertie, Camden, Chowan, Currituck, Dare, Gates, Hertford,
Pasquotank and Perquimans Counties)
Washington District
943 Washington Square Mall Washington, NC 27889
252-946-6481
Fax: [phone]
(Serves: Beaufort, Craven — north of the Neuse River, Hyde, Pamlico,
Tyrrell and Washington Counties)
Wilmington District
127 Cardinal Drive Ext. Wilmington, NC 28405-3845
910-796-7215
Fax: [phone]
(Serves: Brunswick, New Hanover and Pender Counties)
http://portal.ncdenr.org/web/cm/dcm-home Revised 6/01/2021

AGENT AUTpORIZATIQN 'EOR . AMA PIERMIT APPL AMN
Marne of property Owner Requesting Permit. � , �I
V 5A-
Mails Address: elf
Phone Number, R' J
Email Address: {� J&
l certify That f have authorized e-- K-
Agent 1 Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: ,Af� '`'A'
at my property located tit r
e--� 'qY %9
in . -el e s _ County_
l furthermore certify that l ,am authorized to gr8nt, and do in fact grant permission to
Division of Coastal ,Management staff, the Local J°orrnit Officer and their agents to enter
on the aforementioned lands in connection with evaluating information related to this
permit application.
Property Owner
-- Print or Type Name
Title
Elate
This certification is valid through -! _1-

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N.C. OPASION OF COASTAL MANAGEMENT
._,,ENT RtPARIAN PROPFRTY OWNER NOT[FICATIOWWAIVER FORM
,E@gFW0 Mal_ L
R RN
Jn_-8&0F`T R
(TOP POrUOn to be Completed by owner or their agent)
Add(M Of PrDPWY� ),:Vo.5 Aj,5-,c,6g cal- - Zu,--,;,-T
Mr-fxV Addnm of Owner
ownees ownses phoroc
Agenfsf4m,14, AgVA Phones-
AgeWs
ADJACENT RIPARIAN PROPERTY Obi ER'S CERTIFICAT)ON
U2=M ggEfign to be cwmlgod by Ity A!NzcerA Pa=!!X Own
I hdt*by cafUN that I ovm property a6*ent to U%e amwe referenced PrOPertY, The individual appty;pg W this
pgr"t has dgscnbed to rne, as shown an the anachod drww*V, th9 d0vOWnera they are P;096ding 6
yrlp or wi(tr dirnensions b_0 10fl this kdw--
:'I DO NOT have 015*110m tothis PrOPOSA- —41 1 DO have objecbwm to airs PMOO",
it YOU -er"93—v—e to what is !thing proposed, YOU MU3jrjg-j&"y up* "-- — ...... .. . ---
M 001�#)Caq in wrung within 10 days ofmc..,eWetogs r"Wco. Coff"pomlerKeshotildba
"lag
M*nW to 127 Cangns) Drive EKt;, WWmIngfon, NC 2"04,3945, DCU fVFMS0nt3dV0$ can ALSO be
sidwed the SAM* 8S no 041*00n ff you "" be's"
contocMd 4rt [phone]- No r"Pc"" 13 C�on
a*~ by Cartmod if
WAVVER SEC*110"
I Undereand that any pmp*sed pier, dock, rnoorWQ Pi M5. boat rJ", brc*+►'wal r, bomtt sae, r or
groin MUV be set back a ninkroim distance of IV from nly am of ripaAan scem unless m-4wed bY rf*
(this does not W* 10 bukheads or riprop revMMts), (if you wish to waive the sawack you mug
ft appropriate blank beWw,)
I DOvAsh to waive SmWaj of the S!
signawre of Ad)'8cerf ipaian Property owner
-OR-
Uirernqpt (Tf�U�gj"n
I do fWj_wi$�h to wsiVe tM 15, setback mq
Signature of Adjamat Ripatian Property Owner
TypeNPrintod name of ARPO:
fit
MaRing Addre" of ARFO: —iMLW
-�l
ARPO's 6MAII: , ARPIOs PhorsoM
0 *waiver is valid for up to one year from ARPO's Signature'
Date:
Revised Juty 2021

N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
CERTIFIED MAIL - RETURN RECEIPT R9QUESTED or HAND DELIVERY
(Top portion to be Completed by owner or their agent)
Name caw Propett'/ Owner: _ C.ra e t`&r6�-54-14
Address of Property:
Maif ng Address of Owner..
Owner's email: Owner's Phone#:
Agent's Name: � ��` 1 I'�� ��5�,.- � Agent &�f�®net: ��� �..��2--ezde
Agent's Email: i c-_ 11-N, 4-1 L.. C:'�4T
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION!
(Bottom portion to be completed by the Adiacent Property Owner)
I hereby certify that I awn 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 proposipg,
jLesCrkptiorl or drawing. with dimetl4+(N1S /must t1t7 provided Frith this refer,
00 NOT have objections to this proposal_ _ I DO have objections to this proposal.
It you have objections to what i hb►ng propas+ed, -you must notify the N.C. plvision of +Goastaf
Managerjnent (DCM) in writing within 10 days of receipt of this notice. Correspondence should be
mailed to 127 Cardinal Drive Ext_, Wilmington', NC 284a5-3845. DCM representatives can also be
contacted at [phone]. No response is consfdemd the same as no objectron ff 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 to set back a rmnimum distance of 15` from niy area of riparian access unless waived by ma
(this roes not apply to, bulkheads or riprap revetments). (If you wish to waive the setback, you must Sion
the appropriate blank below.)
I DO wish to waive someJ'ail of the 15' setba c,,_
Sig ure of Adjacent ,Riparian Propcay-Oivriar
-OIR• =
I do notwish to waive the IV.setback requirement (tnitiat the blank}-
Signature of Adjacent Riparian Property+ O,tvnes
TypediPrinted name of ARPo: r Q14► t� -
Mailing Address ofARPO:
ARFO's email: 3�d : { N1 = "4"-f itPo Phone#: --
Dater I 'waiver Is valid for up to one year from ARPO's Signature*
Revised July 2021
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