89971A - Stevenson

1lA1 GENERAL PERMIT o"r'� �CAMA ElDREDGE & FILL N9 89971 (A; B C D
a Previous permit 1 /
Date previous permit issued
[ANew ❑ 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.den.nc.gov/CAMArules
Applicant Name
City
Phone#(_)
Email
Authorized Agent
Project Location (County):
State ZIP Street Address/State Road/Lot #(s)
Affected ❑ CW ❑ EW ❑ PTA
AEC(s): ❑ OEA ❑ IHA ❑ UW
ORW: yes/no PNA: yes/no
Type of Project/ Activity
Subdivision
City
❑ ES ❑ PTS Adj. Wtr. Body
❑ SPIMA ❑ PWS Closest Mal. Wtr. Body
17, I (" 4 r•c,IC
(Scale:l "'A) )
Access Length
-
Pier (dock) length
Fixed Platform(s)
-
Floating Platforms)
t'�
t"
Finger IT
�
piers)
Total Platform area
Groin length/fJ —
�__
—I
Bulkhead/Ri ra length
Bulkhead/
,k
Avg distance offshore --
I--
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t
-
-�---
-
-=---
Breakwater/Sill
I
Max distance/length
,
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I
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Cubic yards
Cubic yards
L
1;
-_
1
Boat m
u
_
t
Boathouse/ Boatlift
Beach Bulldozing �'
I
Other
I
-
Oil
SAV observed: yes no
-
---1
I
—
--
-
Moratorium: '. n/a yes no _
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Ir
-
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Site Photos: gD no
Riparian Waiver Attached: 11'V no
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-
A building permit/zoning permit may be required by: 1 )y `:+ % U fi' C�. r` (� �'ti'-� rti�•.t
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 Officer's PRINTED Name
Signature**Please read compjince statementon backof permit-` Signature
Application Feels) Check rt/Money Order Issuing Date Expiration Date

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date 6 - 2
Name of Property Owner Applying for Permit:
?ati.ILlhc�sati cS�evehsov�
Mailing Address:
(011- Rwdr-slo C\A
E I t- 7-4 trA C'k FV , N CG 1-7 q
I certify that I have authorized (agent) to zPA< -T'k or, psO1y to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity) 1��/ �e C k p
at (my property located at) `b k 4 fZ(v-et•5 k0r'C' I�Q
This certification is valid thru (date)
�c w,^- / �-- 6 / Z�
Property Owner Sigm6re Date

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:elx 1 tnQsa� J{@fie
Address of Property:
c 27goq �J
MaflingAddress ofOwner: 1Z0,)9 AV L(ty' IN'--k /!I�-
Owner's email: tJ-,4ye-vvson2 )c,[a .(J. Cons Owner's Phone#: (9 52) Z.02 - 5062
Agent's Name:
Agent's Email:
Agent Phone#:
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom portion to be completed by the Adiacent Property Owner)
I hereby certify that I own property adjacent to the above referenced property. The individual applying for this
permit has d�,wribed to me, as shown on the attached drawing, the development they are proposing. A
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 notny me rv.L.. urvrsron or wasraf
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.)
I DO wish to waive somelall of the 15' setback
Signature of Adjacent Riparian Property Owner
-OR-
4—
I DO NOT wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner:
Typed/Printed name of ARPO: Chxj s+n d �EIQ0, / r AP tY A �
Mailing Address of ARPO:: / 01 io 1WQZL Lie
ARPO's email: G%]f�g2`/ �C/oE•GaM ARPO's Phone#: 64-*147/- 060
Date: �M &x 112 '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. I awl
��fJeVlSom
Address of Property: 10t2-
�irersh�r
Mailing Address of Owner: Saivnc- as G ov(�
Owner'semail IS'hvenSe lr lauQ.co, Owner's Phone#: (157)2U") p
Agent's Name: Agent Phone#: ( /n ' oZ��h r WK9
Agent's Email:
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 forthis
permit has described to me, as shown on the attached drawing, the development they are proposing. A
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.G. Division or Goasrai
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.)
I DO wish to waive some/all of the 15' setback
Signature of Adjacent Riparian Property Owner
-O R-
I DO NOT wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner:
7
Typed/Printed name ofARPO: �w� i—thr)54t i2vch, rr
Mailing Address of ARPO: 12 �i ve rS�oy� oct L , , J)04, L IAAv C 2-7 q Oq
ARPO's email: �S�evewS'>nO l�ok�`-c) n ARPO's Phone#:
Date: 6/5 / i� "waiver is valid for up to one year from ARPO's Signature`
LN
Revised August 2022

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