92539C - Smith, Jason

', Y- C '` €}CAMA i .j DREDGE & FILL (-' �i; f• A B CD
Previous permit ".,_
r -, GENERAL PERMIT --
F 3•• Date previous permit issued
hS ; New _ Modification L)Complete Reissue Li Partial Reissue
As authorized y the S e of North Carolina.Department of Environmental Quality and the Coastal Resources Commission in an area of environmental concern pursuant to:
ISA NCAC.._._. _ � �___. El Rules attached. r General Permit Rules available at the following link:www. ea.rygv/GgQlgl
Applicant Name ,�(; C1' (� Authorized A ent . 0,( ..0
Address..1^w-�J�� - _ �f116„t)".--. ...--- _ Project Location(County):„rls�/rut.. ,
City e-d,�d+1L3C.J L. tate .... _ ,..._.. _._ZIP_..1 .W � Street Address/State Road/Lot#(s).
Phone# 0)- l-.-•___- _- i 3 . 5 - -1401+G--4 -. ___
Email..,•..�_ _ Subdivision______ __._____-_-
— —
City._'x:�� ..���_.___--------� ZIP ?
Affected rim NEW PTA Li ES El PTS Adj.Wtr.Bo :f� ;U.,/� a in lurk)
AEC(s): ElDEA L IHA L UW Ei SPIMA .a PWS Closest Maj.Wtr.Body_-__...---.G 5 S _-.-..
ORW:yes/it) PNA:6110
�`�,, c (-
Type of Project/Activity_J��•� �-- `1�{Y6b UV-L/\_., 4-.:WyV1
-•------"----
(Scale:J .ra t
Shoreline Length ,_,"
Access Length~r.
Pier(dock)length-4"...."`
Fixed Platform �Gp'-, 1-�s) ---� J�TIr'
,........
Floating Platform(s) //�� __,___._ '_^ -- F
Finger pier(s),'r^.________��
Total Platform area l•i
Groin length/N r ___ _•
Bulkhead/Riprap length ---•-" _A_- e C,,lUt �,, 1, A
~
Avg distance offshore.__-� ._ _ l ) 1't /-e 1y} " `
Breakwater/Sill_
f�} /l ii
(J'] (r
Max distance/length �--•, �, _y L
_ i
Basin,channel
Cubic yards ' '''
Boat ramp _ �.— fal ri•ii ti. .,.
Boathouse/BoatliR VP)Js t j A. t� M�� �J S ,� {-
Beach,Bulldozing -_ --_ _ _ 1 L1�1/T'�"'�`�.a 'M(!J V/
SAV observed: yes �-'' l _• l
Moratorium: n/a yes t
Site Photos: yes
Riparian Waiver Attached: yes
A building permit/zoning permit may be require f ))(,L 1 _._
1 �y Q g-- T C TAR/PAM/NEUSE/BUFFER(circle one)
mit Conditi s...\�..(�.,�,1„Q_I .fDi yvA _-.�. _.tJi,dY.. ___ ..(�L.1�e1.��--_Y_t�J._
/D �� ++ ,qi nn 1 �'Jj �
-._--•-- �4� t - 9 _.FAN4(1_.. '*{'_�' tos-)��k .*_.•_._._..... n See note on back regarding River Basin rules
_ _._____. n See additional notes/conditions on back
I AM AWARE OF STATUTES,STTU _ CR,:'"LES AND•COND IONST THAT APPLY TO THIS PROJECT AND REVIEWE•D COMPLIANCE ,TEMENT. (Please Initial)___ ._.,L_t A•
ram
A ram, `r Applic� Name Permit 0 c r'. • e
/V ti 4
Signature"POr
ad compliance statement on back of permit's Si nature
Application Fee(s) Check p/Money Order Issuing Date Expiration Date

I
CQASl4( 9 �•CAMA I I DREDGE & FILL N9 92539 A B CD
—1'
1
I GENERAL PERMIT Previous permit _
Date previous permit issued
New Modification Complete Reissue IIIPartial Reissue
As authorized y the Sta e of North Carolina,Department of Environmental Quality and the Coastal Resources Commission in an area of environmental concern pursuant to:
I SA NCAC 17 4 f 4oO n Rules attached. ❑ General Permit Rules available at the following link:www.dea.nc.gov/CAMArules
Applicant Name 511,5)V) I''!"-N Authorized Agent €//)7t"
Address Project Location(County): �7L I(1(�J-- ,k
.
City rate � ZIP Street Address/State Road/Lot. #( � ��
Phone#D ( 1j1) � I� nrif�l t
Email Subdivision
City packet) ZIP 9 47 O
Affected [ I CW NEW _PTA n ES U PTS Adj.Wtr.BodaArt X C Atp5..ttiAj at //unk)
AEC(s): n OEA fl IHA UW 11 SPIMA PWS Closest Maj.Wtr.Body sJJ.,7L.e
ORW:yes/e PNA:' n�'no ���� (� ,(��
Type of Project/Activity 113 """` c/.�`K{Yro o�-(�,��t'1ti.•� (�
f 1 (Scale:i 11 0
Shoreline Length C25
Access Length
Pier(dock)length ��.
Fixed Platform(s) Ci/. r • '' • , .4
Floating Platform(s) '....— ....
-
Finger pier(s)
Total Platform area aYL
Groin length/# '►-- (�� 1
Bulkhead/Riprap length ---' l�1 `j /�
Avg distance offshore �v Y ���wf(/ _
Breakwater/Sill •— .�� a tJo
Max distance/length - 141+
Basin,channel
Cubic yards_ I lj'
„fir
ne4-
Boat ramp r,
Boathouse/Boatlift l Ei)1Jr X i 3 V A
T '
Beach,Bulldozing
Other 1 U� l,/--- U
SAV observed: yes ._/ ✓
Moratorium: n/a yes o
Site Photos: yes o
Riparian Waiver Attached: yes no
A building permit/zoning permit may be requirec by: 00.J1(4-v
P m�ipt Conditio s 4�% n TAR/PAM/NEUSE/BUFFER(circle one)
'C' o a al C cPa,f q ye ( "�1'Ifn 4. n See note on back regarding River Basin rules
nSee additional notes/conditions on back
I AM AWARE OF STATUTES,CRC RULES AND COND TIONS THAT APPLY TO THIS PROJECT AND REVIEWED COMPLIANCE •TEMENT. (Please Initial)
LC so i - -e ‘ 411.
Agent or Applicant PRINTED Name Permitic rile'RINTED N. e
Signature***PJgase read compliance statement on back of permit** Signature /
01) W()-(Voll
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:
Tar - Pamlico River Basin Buffer Rules 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 Washington District
400 Commerce Ave Morehead City, NC 28557 943 Washington Square Mall Washington, NC 27889
252-808-2808/1-888-4RCOAST Fax: [phone] 252-946-6481
(Serves:Carteret, Craven—south of the Neuse River, Onslow Fax: [phone]
Counties) (Serves: Beaufort, Craven—north of the Neuse River, Hyde, Pamlico,
Tyrrell and Washington Counties)
Elizabeth City District Wilmington District
401 S. Griffin St.Ste.300 127 Cardinal Drive Ext. Wilmington, NC 28405-3845
Elizabeth City, NC 27909 910-796-7215
252-264-3901 Fax: [phone]
(Serves: Bertie,Camden, Chowan, Currituck, Dare, Gates, Hertford, (Serves: Brunswick, New Hanover and Pender Counties)
Pasquotank and Perquimans Counties)
http://portal.ncdenr.org/web/cm/dcm-home Revised 6/01/2021

o,�F COASr4TN I ICAMA f l DREDGE & FILL N9 92539 A BCD
I GENERAL PERMIT Previous permit
Date previous permit issued
❑New I I 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 J -t'° 14,o0 ❑Rules attached. I I General Permit Rules available at the following link:www.deq.nc.gov/CAMArules
Applicant Name 3C L�'.`', -�,_j fi Authorized Agent f nnett ! ' IK,"�1/4..i'� O�/l.'),. _) L/-C_
Address 1 ; �(�1�i.-l-.I 1.4 ('LA.i !C3 ,,, Project Location(County): N ,S/(,( �f"�''
City ,'t(. 1%-_.t 1 SState ZIP Street Address/State` Road/Lot#(s)
Phone#f 3-(,a) (0 l V q'1 1 ;- 1 '111 i 5Lt 1 I f rtk (1 4 Q ✓--
Email Subdivision
City ZIP
Affected fl co. D EW PTA I--I ES PTS Adj.Wtr. m'n/unk)
�'
,)N
AEC(s): I�OEA ❑IHA UW Ill SPIMA
SPIMA ❑PWS Closest Maj.Wtr.Body 311.A p&p S44.4 -lC.,e7
ORW:yes/no PNA:yes/no
Type of Project/Activity .6(71 4.k4 4- cL._ 1 CA M/ ...,pQA At)
"'�
, 1 (Scale: 1r 90
Shoreline Length '
1 i
Access Length -__ ...._.-- _-. _, i '.._ . _.. ....._.._ _...... ..._.._
�...� }
Pier(dock)length"''"' 1 I '
_taicia.il.) 4/ .
Fixed Platforms) 0j 7
Floating Platform(s) `—' {
"..,Ij 1.
Finger pier(s) } _ I * E
I
Total Platform area r-Aa
Groin length/# -.•----. �/ �� ' f . -
Bulkhead/Riprap lengthy �. , _ l
412 I491C1)4C -1 1-
Avg distance offshore ._._. .. _......_... -,_
Breakwater/Sill dI ,
Max distance/length v. - . ,
Basin,channel { j
Cubic yards -_ .„ .._. - ._. 1............... __. ._�
1"L7014-4 r� i __
Boat ramp - �l -- �— ---Boathouse/Boatlift 1 l i ,p2 t,
t `.3 I
Beach Bulldozing - ♦ ■K..
Lie.--.....--- 1
II
Other )f' ---
, _-
SAV observed: yes no,, ` �- ✓ - ..... -`
Moratorium: n/a yes ho I f Site Photos: yes 'no , _ , ,
Riparian Waiver Attached: yes no' . . j .
A building permit/zoning permit may be required(by: j}(1
Permit Conditions "I i L.L ,c 1t lu` ' ; `t '/+ 11 `, i ; : I ❑TAR/PAM/NEUSE/BUFFER(circle one)
s i/(1 ' i i 1 4' lI a ctl J( Lt�`-' ►\ It(l j-((. ❑ 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)
r fi r IN' a LQ -C-C HeCJi iv- )s
Agentor Applicant PRINTED Name Permit Officer's PRINTED N e
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:
Tar - Pamlico River Basin Buffer Rules 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 Washington District
400 Commerce Ave Morehead City, NC 28557 943 Washington Square Mall Washington, NC 27889
252-808-2808/1-888-4RCOAST Fax: [phone] 252-946-6481
(Serves: Carteret, Craven—south of the Neuse River,Onslow Fax: [phone]
Counties) (Serves: Beaufort, Craven—north of the Neuse River, Hyde, Pamlico,
Tyrrell and Washington Counties)
Elizabeth City District Wilmington District
401 S. Griffin St.Ste. 300 127 Cardinal Drive Ext. Wilmington, NC 28405-3845
Elizabeth City, NC 27909 910-796-7215
252-264-3901 Fax: [phone]
(Serves: Bertie, Camden,Chowan,Currituck, Dare,Gates, Hertford, (Serves: Brunswick, New Hanover and Pender Counties)
Pasquotank and Perquimans Counties)
http://portal.ncdenr.org/web/cm/dcm-home Revised 6/01/2021

o60`°' '�N CAMA DREDGE & FILL N9 92539 ABCD
GENERAL PERMIT
II Previous permit
Date previous permit issued
n New n Modification Complete Reissue n 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 5A NCAC n Rules attached. n General Permit Rules available at the following link:www.deq.nc.gov/CAMArules
Applicant Name A ; % Authorized Agent ' '/ )Lc+ i 1;.,1 4) ( L,.`r i E I .) �_.L L....
Address 4�i , `. Project Location(County): LA, Ja L-L..f-'r
City r -- State j\)C ZIP Street Address/State Road/Lot#(s); (}
Phone#( ) ' ' ��1 Il.�.1.( t \.r ( �`t 'N`-^"`,_...,__
Email Subdivision •,
q fUr
City � r'?r'"( i j--f �
i t � ZIP �,
e ,�vt
Affected n cm, DEW J PTA n ES n PTs Adj.Wtr.Body .t(r t i', >, J i l / ";; k� (fnat/man/unk)
AEC(s): n OEA n IHA n UW n SPIMA n PWS Closest Maj.Wtr.Body (..../1% .•'f..( d iL
ORW:yes/no PNA:yes/no
Type of Project/Activity , ,. ,1
(Scale: / =-7p
Shoreline Length t
Access Length . } j i
_ _ t i..
..............
Pier(dock)length
Fixed Platform(s) f� ' 1\ ,) '-` .7*
1___
Floating Platform(s) {
Finger pier(s) {
Total Platform area' i
Groin length/if ! i 1
Bulkhead/Riprap length r i�a.Q� -- j
Avg distance offshore -- - _._ ____ 1 _—.__-----______..__._.._
Breakwater/Sill - t ,
Max distance/length t,., -. j_ i i^l t ., ! 1 1,,,
Basin,channel 1 .%•� i
1 _ ..._.._...._._._ _ _.
Cubic yards
I
Boat ramp 1 I _ µ �i,, ., i . _
Boathouse/Boatlift ' 1 zJ Ii N
ii
Beach Bulldozing ---- --- L ( !
Other ......--.1 �� 1
SAV observed: yes t\,r -- '
rn 1 I
Moratorium: n/a yes o ! I j
Site Photos: yes no { - f j
Riparian Waiver Attached: yes no I - I 1
i
A building permit/zoning permit may be require by:
I ❑TAR/PAM/NEUSE/BUFFER(circle one)
Permit Conditions
, 0 See note on back regarding River Basin rules
nSee 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 if/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:
Tar - Pamlico River Basin Buffer Rules 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 Washington District
400 Commerce Ave Morehead City, NC 28557 943 Washington Square Mall Washington, NC 27889
252-808-2808/1-888-4RCOAST Fax: [phone] 252-946-6481
(Serves: Carteret, Craven—south of the Neuse River,Onslow Fax: [phone]
Counties) (Serves: Beaufort, Craven—north of the Neuse River, Hyde, Pamlico,
Tyrrell and Washington Counties)
Elizabeth City District Wilmington District
401 S. Griffin St.Ste. 300 127 Cardinal Drive Ext. Wilmington, NC 28405-3845
Elizabeth City, NC 27909 910-796-7215
252-264-3901 Fax: [phone]
(Serves: Bertie, Camden, Chowan,Currituck, Dare, Gates, Hertford, (Serves: Brunswick, New Hanover and Pender Counties)
Pasquotank and Perquimans Counties)
http://portal.ncdenr.org/web/cm/dcm-home Revised 6/01/2021

•
Styron, Heather M.
From: Sherry Tipton <[e-mail]>
Sent: Wednesday, October 18, 2023 4:08 PM
To: Styron, Heather M.; Sherry Tipton
Subject: [External] Jason Smith
Attachments: Jason Smith CAMA Docs.pdf
CAUTION: External email. Do not click links or open attachments unless verified. Report suspicious emails with the Report Message
button located on your Outlook menu bar on the Home tab.
Thanks
Check in the mail,
Parris
1

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: Jason
Mailing Address: 0?) M15 �1 I IöiJ Li)
6nead3 Hirr J is c84 O
9 �
Phone Number: q 16 `- 6 6-Cl N q ll'1
Email Address: J6156091)14))it°Lha n )e/ti}4rer uI/ er5; 6.617)
1 ,
I certify that I have authorized i nne-1 ' Mar-1'm! (`, .7 O� 'ITL1C lJ7 6/), LL(,
Agent/Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: /O fi& rt +f/ a el
IA' x Aa) Dock &De•
at my property located at I JJ (r/'i'�" y i / lOU) 1-.!) 5i)e d i ,
in 01)6/!) W 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.
Propert Owner Information:
Signature
Ja 5d n 517 I W)
Print or Type Name
Qw )er
Title
1i_ci)
Date
This certification is valid through I I

•
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; .j1,1/4,1 s~ � ( {J-.. .)
Address of Property: I ? 116 t.l j G •1,) 5'fi7(.4<j I".f. i ". Aetko
Mailing Address of Owner;
I , r� �e1dr)Ctrket. bu;kier''. C?fit
Owner's email: ITIY)/-13'if�'i`�`-.dfk Owner's Phone#; %rr J o ' - 41111
1) h/
Agent's Name:trlirtt Pi 11olL '1 1 Jj(tIC' tot)--`' Agent Phone#: `11'6 ._kl4A1~ .,.. ?),/'7 j•
Agent's Email: cs-'j;ini l ..0'1c't, 111(' 6i!); 11-1.iC A,:t: ;..(I C. iin
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
Avo description or drawing,with dimensions, must be provided with this letter,
'N)r-
,�t'� ✓.�,�/� 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 400 Commerce Ave.,Morehead City, NC 28557.DCM representatives can also be contacted
at(252) 808.2808. No response Is considered the same as no objection if you have been notified by
Certified Mail.
' WAIVER SECTION
r 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
t0 (this does not apply to bulkheads or riprap revetments). (If you wish to waive the setback, you must sign
f) N\ the appropriate blank below.)
I DO wish to waive some/all of the 15'setback
Signature of Adjacent Riparian Property Owner
I do not wish to waive the 15'setback requirement (initial the blank)
\ Signature of Adjacent Riparian Property Owner: •
•
1) 1 Typed/Printed name of ARPO: i7L%
frA �Mailing Address of ARPO: 13`i (�IS�`� �}ol�-o`�- �'' ; 5 V'L22c) / L-Z k16 3
L
‘)'���,�J `1 ARPO's email: It+t2. U1 i '• j ARPO's Phone#:
\'\
(i) Date: /0'3� Z3 *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 NOTIFICATION/WAIVER FORM
CERTIFIED MAIL • RETURN RECEIPT REQUESTED or HAND DELIVERY
(Top portion to be completed by owner or their agent)
t
Name of Property Owner: �,�(5 J I fl 1 7
Address of Property: I M 5 L -116 (lbw Ldi) (5-0C itcI5 Teri Li NC. AV66
Mailing Address of Owner: 1, ct
Inc, J
c lAnneft4ctrkerbul* S•alp
Owners email: V-15Oi in/-U Owner's Phone* gib -651- g
Agent's Name:LI)t i ° *ally(ald bztQc()i)lic Agent Phone#: ! I b 's Ll(X"l""(J4i�/15
Agent's Email: enirl it al Inc Cidi)i -t-tc' noh61> j -tl• COM
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom portion to be completed by the Adjacent Property Owner)
14 vs
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.
V.' gkiDO 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 400 Commerce Ave.,Morehead City,NC 28557.DCM representatives can also be contacted
at(252) 808-2808. No response is considered the same as no objection if you have been notified by
Certified Mail.
el WAIVER SECTION
(l 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
v the appropriate blank below.)
I DO wish to waive some/all of the 15' setback /y,
Signature of Adjacent Riparian Property Owner
-OR-
I do not wish to waive the 15' setback requirement(initial the blank)
\e"\le' Signature of Adjacent Riparian Property Owner: '24._
ZeyA.. . ='
11 i\ R Typed/Printed name of ARPO: Abei� � plain A elimed5
�1 Mailing �l Address of ARPO: P� Q /
1 Ae A/'G 2U'( '
0‘1A\ ®0 ARPO's email:t G'"4r1114.�,( e1 .C4�h ARPO's Phone#: co) 67/ `"67�Qi
`` (i Date: o-(7 202 *waiver is valid for up to one year from ARPO's Signature*
Revised July 2021

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