89763A - Pereira

°� ❑CAMA ❑DREDGE &FILL NU 89763 a (L A`' B C
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 9 al ' 2 i r` ' ❑ Rules attached. M-General Permit Rules available at the following link: www.deq.nagov/CAMArules
Applicant Name
Address / It Do 1L //+24.5'%n <-' r_,<`-r...)...
City <X I e , <�, k State N C_ ZIP V
Phone # _(wF,Z. )l / (Uy"J, 1r 7_ c/ /
Email it 4- 5 � I CJ � < — A', ) , a a ; s.
Authorized Agent 41r 'k.
Project Location (County):" -
Street Address/State Road/Lot #(s)
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City [Jµ ,<: -4--> .. ZIP I - -% � ..� ..
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Affected ❑ CW ❑ EW PTA ❑ ES ❑ PTS b Y /J (. t/man/unk)
AEC(s): ❑ OEA ❑ IHA ❑ UW ❑ SPIMA ❑ PWS Closest Mal. Wen Body 1/ l� r
ORW: yes/no PNA:yes/no ;!
Type of Project/ Activity n s f, r !>? i n I
(Scale: p/ 7 )
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Shoreline Length 2 J
Access Length
Pier (dock) length
Fined Platform(s)
Floating Platform(s)
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Fing er P ler(s)
Total Platform area
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Groin length/q
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Bulkhead/ Riprap length
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Avg distance offshore
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Breakwater/Sill
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Max distance/length
Basin, channel'
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Cubic yards
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Boat ramp
Boathouse/ Boatlik
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Beach Bulldozing
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Other
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SAV observed: yes no
Moratorium: n/a yes no
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Site Photos: yes no
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Riparian Waiver Attached: . yes. 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
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
Signature -*Please read compliance statement on back of permit"
Application Feels) Check q/Money Order
Permit Officer's PRINTED Name
Signature
,
Issuing Date
Expiration Date

TION TO ACT AS REPRESENTATIVE FORM
Property Legal
DEED BOOK: I 1283 PAGE NO: 518
STREET ADR SS: 47052 Rockv Rol linson. Road Buxton NC 27920
Please Print:
Property Owner: Charles Pereira
Property Owner:
The undersigne property owners of the above noted property, so hereby authorize
Dou Dorman of Atlantic Environmental Consultants LLC to,
(Contractor/A ent) (Name of consulting firm)
1. Act on my behalf and take all actions necessary for the processing, issuance and
acceptance of permits and/or certifications and any all standard and special
conditions attached.
2. Enter the property to obtain site information including inspections with regulatory
agencies (Dare County, North Carolina Department of Environmental Quality,
U.S. Am ky Corps of Engineers, etc.) for the purpose of obtaining permits and/or
Property Owner Address (if different than property above):
Property
We hereby cer
accurate to the
Date:
Telephone Number: 252-216-6291
that the above information submitted in this application is true and
t of our knowledge.
and Title
Authorized Signature and Title
Date:
This certiftcatioN is valid thru (date)
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PEREIRA
CAMA GENERAL PERMIT
CHARLES PEREIRA
47052 ROCKY ROLLINSON ROAD
BUXTON — DARE COUNTY — NORTH CAROLINA
zy 050'
loo,150
ATLANTIC MYRON,1/L'NTAL CONSULTANTS, ILO
GRAPHIC SCALE 1'- 50•
P.O. BOX d166, K/?Y llM,, N.C. 279,0
(151)16/-7707, a-maB 6mgobwiVmi7&com
iRE PERDRA CP DAM DsIDeIz,T
RENSD:

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:
Charles Pereira
Address of Property: 47052 Rocky Rollinson Road, Buxton, NC 27920
Mailing Address of Owner: 1008 Mlegson Court, Raleigh, NC 27614
Owner's email: [e-mail] Owner's Phone#: [phone]
Agent's Name: Doug Dorman Agent Phone#: [phone]
Agents Email: [e-mail]
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 drawin% with dimensions, must be provided with this letter.
I DO NOT have objections to this proposal. I DO have objections to this proposal.
7f you nave objections to wrier is being proposed, you must notify the N.c. uivision or coastat
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.
WA1VER SECTION (Choose only one)
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 Z%
Suture 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: John Smith
Mailing Address of ARPO: 33576 S Main Street, Townville, PA 16360
ARPO's email: [e-mail] ARPO's Phone#: [phone]
Date: 05/01 /23
*waiver is valid for up to one year from ARPO's Signature"
Revised August 2022

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:
Charles Pereira
Address of Property: 47052 Rocky Rollinson Road, Buxton, NC 27920
Mailing Address of Owner: 1008 Megson Court, Raleigh, NC 27614
Owner's email: [e-mail]
Owners Phone#: [phone]
Agent's Name: Doug Dorman Agent Phone#: [phone]
Agent's Email: [e-mail]
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.
J1 DO NOT have objections ((o this proposal. I DO have objections to this pr os�I.
A A.." A _ /IA A, .•./) AA A. rAr A - , <' ITT 1 1 2
If you have objections to what is being proposed, ybu must notify the N.G. Division or 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 (Choose only one
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.) ,/ nn jfl�Jr
I DO wish to waive some/all of the 15' setback W ✓" 31 �f ' V
Signature of Adjacent Riparian Property Owner
-OR- W19iVK� /'All P^ 9Ji.9Si q Sill 0 ✓Cl• 1 /iLA✓ 0n/
I DO NOT wish to waive the 15' /s1etback requirement (initial the blank)
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is t' L P Pit fit'/',,l 1' A04 e rF4.4-1 A / 11 a { ; A A
Signature of Adjacent Riparian Property Owner:
Typed/Printed name of ARPO: Bill Holland
Mailing Address of ARPO: 2402 Wistar Street, Henrico, VA 23294
ARPO's email: [e-mail]
Date:
05/04/23
ARPO's Phone#: [phone]
*waiver is valid for up to one year from ARPO's Signature*
Revised August 2022

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