87006A - Zemaitis

#F-]New
❑CAMA ElDREDGE & FILL N9 87006 A B C D
GENERAL PERMIT Previous 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:
I SA NCAC ❑ Rules attached. ❑ General Permit Rules available at the following link: w deq.nc.gov/CAMArules
Applicant Name
City
Phone # ( )
Email
State ZIP
Authorized Agent
Project Location (County):
Street Address/State Road/Lot #(s)
Subdivision
City
Affected ❑ CW ❑ EW ❑ PTA ❑ ES ❑ PTS Adj. Wtr. Body (nat/man/unk)
AEC(s): ❑ OEA ❑ IHA ❑ uW ❑ SPIMA ❑ PWS Closest Mal. Wtr. Body
ORW: yes/no, PNA: yes/no
Type of Project/ Activity
(Scale:` )
Pier (dock) length _
Fixed Platform(s)■■®
N
1
••
:OM�■Floating
�
ON
■
�1■■s
0
No
�■■■
■■■■
■:
Platform(s)
::■■:::�:::�::■■■■::III
:::
■.::�:.
..::.::::CI
III
:.::■.•:,
Finger pier(s)
11
loon
ME
0
MEN
OMEN
Total Platform area
■.■.�■.�v::■■.■■■■■■■.......
Groin length/# Bulkhead/ Ripr
M.
Other
.■.
.1111
rol:...
.....
■0=111111!
■:■WN
MimsN■�
Pill
:c��::�::®:::.::E::::::.::
A:•■•■:•:
ri
..:::::•:SAV
a
..a::::�::�.......�.0
observed: yes no
Moratorium: n/a' yes no
Site Photos: yes no
Riparian Waiver Attached: yes no
.�t..:.
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
TAM AWARE OF STATUTES, CRC RULES AND CONDITIONS THAT APPLY TO THIS PROTECT AND REVIEWED COMPLIANCE STATEMENT. (Please Initial)
Agent or Applicant PRINTED Name
Signature --Please,read compliance statement on back of permit•
Application Feels) Check #/Money Order
Permit Officer's PRINTED Name
Signature'
Issuing Date Expiration Date

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: 11Da.5 7 4t�614 — ZCIVI d S
Mailing Address: 4 Q b&VAC' C
Phone Number:
Email Address: , / �/�
I certify that I have authorized �C(�i�( e� ��`�Ih''� �'� C--
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
3co -4 aelol&-d3L-1 R..D- VZAio
at my property located at 3 d U SM a 6( C(:Z_ c-' 4,, /-I C-
in►art� County.
I furthermore certify that 1 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 Owner Information: /
Signature
Print or Type Name
OL""-% 4/
Title
l( l*;�S f2-3
Date
This certification is valid through
Q�

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: eDAS T At tslex. zen^G'4 Is
Address of Property: 3 Ur S MA t 1 W'1+'"_- r.rz . 04rY1- n C
Mailing Address of Owner: �� M� (� � Make,CS/ L�12 . ei`4f n
�^1�P, i
Owner's email: // Owner's PhoneM c�71"5`7/3 - B 0
Agent's Name: 4`R Agent Phone#: /Y!l,
Agent's Email: 4104
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.
v I DO NOT have objections to this proposal. I DO have objections to this proposal.
H 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 i
-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:
Mailing Address of ARPO:
ARPO's email: ARPO's Phone#:
Date: & - w - 2,_� "waiver is valid for up to one year from ARPO's Signature`
Revised July 2021

■ Complete items 1, 2, and 3.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
1. Article Addressed to: I 1
me►;ssfl t 5Co++ Ac d�--' ctc
16� c�rlan Al,t:
IIIIIII�IIIIIIIIIIII'IiIIIIIIIIIIIIIi IIIIIIIII
9590 9402 8085 2349 4992 67
7022 3330 0001 1256 4162
PS Form 3811, JUIy 2020 PSN 5530.02.000.9053
A. Sig�ture I\
X .f/� ❑ Agent
❑ Addressee
B. eceived by (Printed Name) 19. Date of Delivery
Is delivery address different from item 1? u Yet
If YES, enter delivery address below: ❑ No
3. Service Type
❑ Priority Mail Express®
❑ Adult Signature
❑ Registered MalllM
❑ Adult signature Restricted Delivery
❑ Registered Mail Restricted
❑ Certified Mail®
❑ Certified Mall Restricted Delivery
Delivery.
O Signature Confirmation"
❑ Collect on Delivery
O Signature Confirmation
❑ Collect on Delivery Restricted Delivery
Restricted Delivery
^ Insured Mail
Insured Mail Restricted Delivery
(oyer$600)
pomestC'Return Receipt ;

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