86750A - Grgurich, Rosa & Jacob

�.�t°"rkN❑CAMA ❑ DREDGE & FILL �l N9 86750 A B c
a Previous permit
a GENERAL PERMIT Date previous permit issued
fi,c -,\1301 i-
❑ 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.gov/CAMArules
Applicant Name
Address
City State ZIP
Phone #
Email
Affected ❑ CW
AEC(s): ❑ OEA
ORW: yes/no
DEW ❑PTA
❑ IHA ❑ UW
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
i
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 required by:
Permit Conditions
❑ ES ❑ PTS
❑ SPIMA ❑ PWS
Authorized Agent
Project Location (County):
Street Address/State Road/Lot #(s) _
Subdivision
City ZIP
Adj. Wtr. Body 1 I It ' (nat/man/unk)
Closest Maj. Wtr. Body
(Scale/UTs )
❑ 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 ssuing Date Expiration Date

DIVISION OF COASTAL MANAGEMENT
AGENCY FORM FOR PERMIT APPLICATIONS
I b fil >SQ. �rA u r I G��_ ov%mer of the property located at:
(propemy owner_10-7
do hereby authorize
cc ,ng as agent)
to act as my agent for the purpose of ob =nc :.r= Area Management Act and/or
Dredge and Fill Act permits, that may be nei�� _: - e _J---laosea development at the above -
indicated property, which entails:
710-mma • WW1
(describe proposed development, -,or , h• --h permits are being sought)
This agency authorization is limited to the specific activities described above, and will expire on:
: ag nc; authorization expires)
cq0 SP-P a0aa
(title, if officer of corp. owner or trustee for property)

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: j`?"
Address of Property: t) Z T loueice-< S+;t ry �C �7ci S
Mailing Address of Owner: 2-19 C hAy-J P YYV4a h1,---1 O( r,
Owner's email:-E-GTX D 03 @ 001- . c-O"bwner's Phone#:
Agent's Name: Viav Agent Phone#: 7 C 7 - 2373 —0
Agent's Email 1-1Z 1J L4A t 2�� �'yriL4r
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.
eQ_ 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'
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: (J
Mailing Address of ARPO:
ARPO's email: �(
Date:,( t �,� /}.Oa -I— *waiver is valid
I
Revised May 2021

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: _ ►^ee5 b T-
Address of Property:
Mailing Address of Owner:
Owner's email:- CGr)
Agent's Name:
Z3435
. —sz
Agent's Email >J?AWC 2S2L0 C--Y►'IR.I
Agent Phone#: 2 SZ - 23r3 -a_3(u
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.
7 1 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
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: Y .J�Q (Os k, 0 /s p Ki
Mailing Address of ARPO:9%D
ARPO's email: A. ARPO's Phone#: )e
Datewaiver is valid for up to one year from ARPO's Signature*
Revised May 2021

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