87067A - Reynolds, Mae - (MOD)

�a0tW4, WC4MA ❑ DREDGE & FILL NU 87067 �2 A B C D
GENERAL PERMIT Previous permit
Date previous permit issued
®New AModification El 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. F,,,] General Permit Rules available at the following link: www.deq.nc.gov/CAMArules
Applicant Name Y'•J Authorized Agent
Address .6 Project Location (County): _
City State ZIP Street Address/State Road/Lot#(s)
Phone#O
Email Subdivision
City ZIP
Affected 0 CW ❑ EW ❑ PTA ❑ ES ❑ PTS Adj. Wtr. Body (nayman/unk)
AEC(s): ❑ OEA ❑ IHA ❑ UW ❑ SPIMA ❑ PWS Closest Mai. Wtr. Body
ORW: yes/no PNA: yes/no
Type of Project/ Activity
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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
I AM AWARE OF STATUTES, CRC RULES AND CONDITIONS THAT APPLY TO THIS PROJECTAND 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 #/Money Order
Signature
Issuing Date Expiration Date

N.C. DIVISION OF COASTAL MANAGEMENT RECEIVE®
ADJACENT RIPARIAN PROPERTY OWNER N0TIFICATI0N/WAIVER FORM
CERTIFIED MAIL • RETURN RECEIPT REQUESTED or HAND DELIVERY BE 0 4 208
(Top portion to be completed by owner or their agent)
Name of Property Owner:
<F?Yl_i �• �y�
Address of Property: W 5 J•
Mailing Address of Owner: 2 • 2?q±1
Owner's email: YrOke�(2�-OKA• C.oyh Owner's Phone#: ?9i-61t5-- D045
Agent's Name: Agent Phone#:
Agent's Email:
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 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 notffy 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.
t./_\P/4NIR-1* i7iCOILT
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
-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 ofARPO: r. n
�
ARPO's email: Yl2�n; ARPO's Phone#:%,)�A2 0 -0
Date: 1 Z - 1- a 3 *waiver is valid for up to one year from ARPO's Signature*
Revised July 2021
9 L�

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: Mae_ r--olc.H 2Gyy4o(C�d
Address of Property: tos P, T -rQK� Sf
Mailing Address of Owner:
lOS S•
f oti\f
r
tir c
gC, O�R4tF
Owner's email: rnateAv�
AA Aol. oovh
Owner's Phone#:
'79 1-
JW;- 3*45
Agent's Name: Agent Phone#:
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 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
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.
iTIN-11 VI4 [Ux0111 11M 1I
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
-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: 0 f h It, / ki- %1/ r : 1-4
Mailing Address of ARPO: / 0 3 S . ( � ., 5
ARPO's email: C4w4, !/*^ 15 �2 s *�.:,l, ec,— ARPO's Phone#:
-/y3 °l67 7vv
Date: r1() 6 2Z *waiver is valid for up to one year from ARPO's Signature*
Revised July 2021

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N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONMAIVER FORM
CERTIFIED MAIL RETURN RECEIPT REQUESTED or HAND DELIVERY
(Top portion to be completed by owner or their agent)
Name of Property Owner: MDe Ede ok&
Address of Property: Las S• �t S:}•fir��ord, ntC
Mailing Address of Owner:
VOS S. T-rPA
S} . Ile rAr9rd
C
��
Owner's email: YYId4-pe
n a aol• CPvh
Owner's Phone#:
l5i-9197- ;�s
Agent's Name: S66a. W h(6e,
Agent's Email:
Agent Phone#: a53- 331- 5019
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.
1 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 (DC" 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
-OR-
I DO NOT wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner:
Mailing Address of ARPO:
ARPO's email:
Date:
ARPO's Phone#:
"waiver is valid for up to one year from ARPO's Signature"
Revised August 2022

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AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: 4Jl� r-devi �euv,ot
Mailing Address:
Phone Number: -70- Ats-
ads
Email Address: Mace- dev"@ aot- cwvr
I certify that I have authorized
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: wrx{T zUo-
at my property located at tog S. 't=rovv%,- 4!iA*-or4 , ►SC a-tayy
in pe r011niM&'41S County.
I furthermore certify that / 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:
Sighaturi
µAS S-G t 44 • Rey No �S
Print or Type Name
Title
03 / t\ t 102
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: iv12C-. edwr1 (fie uhddS
Address of Property: dos S- Vr - ��rgd, I'C
Mailing Address of Owner: Ios S- ( :4 - AM42yct, `Ac
Owner's email: rrweedev,La aoj• COwl Owner's Phone#: 757- alts- 31l{6
Agent's Name: P." WWhke- Agent Phone#: ,6;L' 3.37- 50161'
Agent's Email:
ADJACENT RIPARIAN PROPERTY OWNER's CERTIFICATION
(Bourn 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
I DO NOT have objections to this proposal. I DO have objections to this proposal.
If you have objections to what is being proposes, you must notify the mv. urwslan or coasm,
Management (DC" 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 Mall,
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 Inust sign
the appropriate blank below.)
I DO wish to waive some/all of the 15' setback
Signature of Adjacent Riparian Property Owner
-OR-
I DO NOT wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner:
TypediPrinted name of ARPO: C .T f2
Mailing Address of ARPO:
ARPO's email:
Date:
Phone#: �/ o % /3 L y L
*waiver is valid for up to one year from ARPO's Signature"
Revised August 2022

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