87065A - Pellini

❑CAMA ❑ DREDGE & FILL N9 87065 A s C D
ga Previous permit
. G E N E RAL 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:
15A NCAC ❑ Rules attached. FLJ� General Permit Rules available at the following link: www.deq.nc.¢ov/CAMArules
Applicant Name R2111 r I> c>_ I I I h t
Address (C>C.1 `,.'� r� x, r,�- T.e,' C rt t &>
City t ; r : t. c! State NC zip 1 19 `i 'J
Phone#(15-7) q9`54K
Email
Authorized Agent 1
Project Location (County): r 1
Street Address/State Road/Lot#(s) r !'t': ` -
Subdivision
City ZIP
Affected ❑CW [�fEW PTA [5ES 1iPTS Adj. Wtr. Body '.i .I -iI'; ri.. (nat/man/unk)
AEC(s): ❑OEA ❑IHA ❑UW ❑SPIMA ❑PWS Closest Maj. Wtr. Body
ORW: yes/not PNA: yestg:D
Type of Project/ Activity
(Scale:1 2 o)
< -:, 11.1
Access Length
Pier (dock) length■■i■■:■u®■i�■■■■■■■■r�■■■■■
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Floating Platform(s)
Finger pier(s)
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Total Platform area
Avg distance offshore
Max distance/iengt
channel■■■■■■■/It■
Cubic yards
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Other
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A■WBasin,
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111,116-0
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ME
541
Mai
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Site Ph..
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A building permit/zoning permit may be required by: U [n'�"-fie
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
Agent or Applicant PRINTED Name
Permit Officer's PRINTED Name
Signature *"Please read compliance statement on back of permit**
Application Feels) Check q/Money Order
Signature
Issuing Date

AGENT AUTHORIZATION FOR LAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit hal(i Ae,
Mailing Address. /2 .5a? &rl ,- 'lame,
Phone Number. % G lS 8/
Email Address' _1
1 Certify that I have authorized —_.2lfri h 5hd
Agent I CAntractor
to act on my behad, for the purpose of applying for and obtaining all LAMA permits �J
�
necessary for the following proposed development. 7 %1 OTP %rt r tilt e4-1 "
at my prop" located at /00 /Cq h to ge 1-44P
in ,Ul'Y'r7Lr�/� County.
I fudhemere oerW that I am authorized to grant, and do in tact grant permission to
Division of Coastal Management staff, the Local Permit Officer and their agonts to enter
on the aforementioned lands in connection with evaluating information related to this
Permit application.
Prope rinto on:
fJ gnature
Y
Print or Type Name
Td'le2
Date
This certification is valid through ------ / i--,

N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFIEGAoTIONANDAIVER ERFORM
CEI
CERTIFIED AIL
(Top portion to be completed by owner or their agent)
Name of Property Ownerph j�Y ��e��
Address of Property: 11» Seca- V
Mailing Address of Owner:
Owners emit;
Agent's NameUr e Rr��
Agent's Email:
Owners Phone#:IG2_ 0
Agent Phoneflaw -
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom portion to be omelated b the Adjacent Pfeaerty Ownerl
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 , battached ddrawin , he development they are proposing. 9
r I I tlm b
yK I'DO NOT have objections to this proposal. _. I DO have objections to this proposal.
If you have obJ.". to 'hat is wng proposed, you must notify fire 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 sameas no Objection If you have been
notified by Certified Mail.
WAIVER SECTION (Choose only onel
I understand that any proposed pier, dock, mooring pilings, boat ramp, breakwater, boathouse, Ilfl, or
groln must be set back a minimum distance of 1F from my Brea of if aria ccess unless waived by me
(this dcea not cooly to bulkheads or rlorao revetmenlsl (If you wis waive a setback, you must si n
the appropriate blank below.)
I DO wish to we" somelall of the 15'setback
Signature of Adjacent RIP rty Owner
-OR-
1 DO NOT wish to waive the 15' setback requirement (initial the blank)
Mailing Address of ARPO:
ARPO's email: ARPO's PhonWW2 7)6:n- 4lz2
Date 'waiver Is valid for up to one year from ARPO's Signature'
Revised August 2022

M.G OWM OF COASTAL TAANADEMENF
ADJACENT RS'ARWi PROPERTY OWNER NOTIFILAINIMMAN'ER FORM
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(top PDI)IDn b be 0MVIolad by tPA•t9t IN ih9e NOW)
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