86858A-Sierra

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❑CAMA [IDREDGE & FILL N9 89712 Q(L A B C D
Previous permit
GENERAL PERMIT
Date previous permit issued ❑ 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. 0 General Permit Rules available at the following link: www.deq.nc.nov/CAMArules
Applicant Name Authorized Agent
Address Project Location (County):
City State ZIP Street Address/State Road/Lot #(s)
Phone#O
Email Subdivision
City ZIP
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 -
(Scale: + )
Eh
Access Length
i
—
—__.__..
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Pier dock)length
Fixed Platform(s)
•—�-»
.,.
Floating Platform(s)
Finger pier(s)
Total Platform area i
e L
'
t
�
P
Groin length/q
Bulkhead/ Riprap length
Avg distance offshore __I
Breakwater/Sill
Y t
•
l{
1-_
'_
...
_...
-__..—
_
--�-
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Max distance/ length
Basin, channel ,J
Cubic yards
4
1
Boat ramp
_
I
Boathouse/ Boatlift a
i
�_
Beach Bulldozing
Other ��i(�.
_
SAV observed: yes no
Moratorium: n/a yes no
Site Photos: Yes no
Rioarian Waiver Attached: ves no
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A building permit/zoning permit may be required by:
Permit Conditions
❑ TAR/PAM/NEUSE/BUFFER (circle one)
❑ See note on back regarding River Basin rules
❑ See additional notes/conditions on back
1 AM AWARE OF STATUTES, CRC RULES AND CONDITIONS THAT APPLY TO THIS PROJECT AND REVIEWED COMPLIANCE STATEMENT. (Please Initial)
Agent or Applicant PRINTED Name
Signature **Please read compliance statement on back of permit**
Permit Officer's PRINTED Name
Signature
Application Feels) Check ft/Money Order Issuing Date
Expiration Date

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
r-� 11 �
Name of Property Owner Requesting Permit: �%iJW&-XCl �i alr4
Mailing Address: 1`l�tto (�ic� (vim
C.Oc-0lic.
Phone Number: �� 1 e �b r -7 ? IU
Email Address: I GEC 2�1�tG4> t�wi t f Cow,
I certify that I have authorized t3e�dn ty���k�ts UtUr%taU �•
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: I H t` A f�ar�} i tort
at my property located at
in , UrYt 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 0 ner Information:
Signature
�?rint or Type Name
u �1Gv
Title — ---
Z 0� -�
Date
certification is valid through 0 v'? 1 7-0 Z-

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: Lj k"OLi2i S fJr cti
Address of Property: �i� b�cs iS°� f2c�• 66,(t. ✓I C 779 Z-i
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Mailing Address of Owner: (tl 4 tc ,D -a �Cvr tJ-�` y LtA"�4� k n G y%Ct Z�2
Owner's email: ( r-ffy& 2G 2yo14g � I Owner's Phone#: 3-1 - �(oy - 7 � )a
Agent's Name: 13sa,f� I r Uk'L9,dS Agent Phone#: Z72—
Agent's Email: 1�/r4C�'r b t�h.¢ccts niia i ` - CO rv'
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.
IDO NOT have objections to this proposal. I DO have objections to this proposal.
ff 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 (in'ktial the blankl_
Signature of Adjacent Riparian
Typed/Printed name of AR`PO�: � I LA . -(
Mailing Address of ARPO: ` 6---a'OX J(oI Ct 6 o I tG,
ARPO's email: CZ 9, OQ c! hXM�l 4 ARPO's Phone#: Qda' a- a3 `�
Date: g c
3aj *waiver is valid for up to one year from ARPO's Signature*
Revised July 2021

N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
CERTIFIED MAIL •RETURN RECEIPT REQUESTED or BAND DELIVERY
(Top portion to be completed by owner or their agent)
Name of Property Owner: IUD jG
Address of Property: 022 (1 .Sri r �{-,�;//5� /"n ro��a ✓�G 2'7 5'�i _
Mailing Address of Owner. /It ry 4 �i raah-n (�,�., .i (ov /�a Ylc 2.79Z-7
Owner's email: s&O c, C to (eZ 4b k, lZra r's`PhhoTne#;
Agent's Name: /Meer -A Bbl"-- s Agent Phone#: ZSZ-Zoi -G,17
Agent's
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom portion to be completed by the Adjacent Property Ownerl
1 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
desyriotion or drawing with dimensions must be Provided with this teller.
X, 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 (0CM1 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
1 understand that any proposed pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift. or
groin must be set back a minimum distance of Whom 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 sometall of the 15' setback
Signature of Adjacent Riparian Property Owner
-OR-
k'. i do not wish to waive the I5'setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner:
TypedfPrinted name of ARPO: f^o: ,.N, •k''
Mailing Address of ARPO: Jc?�, . 1-22,± Vo - _,L�+• kwo ii-s �j�r.-�,
ARPO's email:5 49 `Ld'ARPO s hone#:
Date: V-q _ 1. Za2.5 *waiver is valid for up to one year from ARPO's Signature*
Revised July 2021

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