87122A - PYOB OBX LLC

#[]New
❑CAMA ❑DREDGE & FILL N9 87122 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. 2 General Permit Rules available at the following link: www.deo.nt goy/CAMArules
Applicant Name
Authorized Agent . I i
Address
1
Project Location (County):
City
State ZIP
Street Address/State Road/Lot#(s)
Phone # (_ )
Email
Subdivision
City ZIP
Affected ❑ CW
n EW u PTA ©ES
❑ PTS
Adj. Wtr. Body (nat/man/unk)
AEC(s): ❑ OEA
❑ IHA ❑ UW ❑ SPIMA
❑ PWS
Closest Maj. Wtr. Body -(`.. -,% F V f. A,
ORW: yes/no
PNA: yes/no
+
Type of Project/ Activity t o
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Access Length `
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Pier (dock)length
Fixed Platform(s)
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Floating Platform(s)
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Finger pler(s)
Total Platform area I
Groin length/q
Bulkhead/ Riprap length
Avg distance offshore
Breakwater/Sill
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Max distance/length
Basin, channel
Cubicyards
Boat ramp
Boathouse/Boatlik
Beach Bulldozing
Other.
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SAV observed: yes no !
Moratorium: ( n/a yes no c ry
Site Photos: yes no
Riparian Waiver Attached: yes no
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A building permit/zoning permit may be required by:
Permit Conditions
❑ TAR/PAM/NEUSF/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 compliance statement on back of permit**
Application Feels) Check A/Money Order
Signature
Issuing Date
Expiration Date

AUTHORIZATION TO ACT AS REPRESENTATIVE FORM
Property Legal Description:
DEED BOOK: 2477 PAGE NO: 0691
PIN NO.: 995015537393
PROPERTY STREET ADRESS: 1324 Duck Road, Duck, NC 27949
Please Print:
Property Owner: Pybo OBX, LLC
Property Owner:
The undersigned property owners of the above noted property, so hereby authorize
Doug Dorman of Atlantic Environmental Consultants, LLC to,
(Contractor/Agent) (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. Army Corps of Engineers, etc.) for the purpose of obtaining permits and/or
certifications.
Property Owners Address (if different than property above):
69 Van Cortlandt Avenue, Ossinine, NY 10562
Property Owners Telephone Number: 914-260-2701
We hereby certify that the above information submitted in this application is true and
accurate to the best of our knowledge.
LLC Managing Member
Authorized Signature and Title Authorized Signature and Title
Date: 01 /16/2024

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: Pybo OBX, LLC, Mark Burnstein
Address of Property: 1324 Duck Road, Duck, NC 27949
Mailing Address of Owner: 69 Van Cortlandt Ave, Ossining, NY 10562
Owner's email: [e-mail] Owner's 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.
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
malted to 943 Washington Square Mail, Washington, NC 27889. 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
1 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 dprap revetments). (if you wish to waive the setback, you must slgn
the appropriate blank below.)
I DO wish to waive some/all of the 15' setback
Signature of Adjacent Riparian Property Ov✓ner
IiIM.
I do not wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner:
Typed/Printed name of ARPO: Martin Schweitzer
Mailing Address of ARPO: 2321 Huntington Station Ct., Alexandria, VA 22303
ARPO's email:
mARPO's Phone#:
[e-mail] 571-319-3449
Date: 12/19/23 *waiver is valid for up to one year from ARPO's Signature*
Revised July 2021

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