89012A - Rothrock, Kaye

❑CAMA ❑ DREDGE & FILL N9 89012 flA) B C D
GENERAL PERMIT Previous 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:
I SA NCAC O'l " ' t C.!Y 1 ❑ Rules attached. ®General Permit Rules available at the following link: www.deq.nc.gov/CAMArules
Applicant Name nLr � c7 C
Address `pr.�• .Z -4- 7
city C4411 �/ State ),j c_., zip
Phone # (,%i`L_.) 17 S ::-..40 C -3
Email
Authorized Agent
Project Location (County):
Street Address/State Road/Lot #(s)
Subdivision.
City i L
Affected ❑ cW EW ❑ PTA ❑ ES ❑ PTS Adj. Wtr. Body O tn/ eCj tt ` (nat/man/unk)
AEC s : OEA IRA UW SPIMA PWS
O ❑ ❑ ❑ ❑ ❑ Closest Maj. Wtr. Body (.., iJ r 1" 1 + U C;
ORW: yes/no PNA: yes/no
Type of Project/ Activity
(Scale:i' r )
Shoreline Length _
Access Length
Pier (dock) length _
Fixed Platform(s)
Floating Platform(s)
Finger pier(s)
Total Platform area 4 C)
Groin length/#
�I I
Bulkhead/ Riprap length = ¢
Avg distance offshore
Breakwater/Sill
Max distance/ length
Basin, channel
Cubic yards
Boat ramp
Boathouse/ Boatlift
Beach Bulldozing !}
Other
SAV observed: , yes no
Moratorium: n/a.yes no�—
Site Photos: :yes no T i �Q'jFs 4 a
Riparian Waiver Attached: yes no
A building permit/zoning permit may be required by: k 1
( �TAR/PAM/NEUSE/BUFFER (circle one)
Permit Conditions
❑ 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 backof permit" Signature
Application Fee(s)
Check #/Money Order Issuing Date
Expiration Date

AGENT AUTHORVgTiON FOR CAMA P
''// �RMITgpp firer
Name of Property Owner Requesting,yyl
permit: 42 E
Mailing Address:
Phone Number:
z�z 333 -��s3
Email Address
I certify that I have authorized 'Dar sy �� to
Agent /Contractor --'
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
at my property located at SPCA
in it C-- (:- 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.
Property Owner Information:
A�
Signature
�GfCfP. l 0 % r6q(
Print or Type Name
Ou�tier
Title
Date
This certification is valid through _i i

ADJACENT Rip C, DMSION OF COASTAL MANAGEMENT
CERTIFIED tiae1ARiAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
gET�RN R1.�CEIP7 RFOLESTED or Hayn n
ELIVERy
Name
Address of Property:
Meting Address of O
(Top portion to be Completed by Owner or their agern)
Owner's email: Owner's Phone#
Agents Name: Agent ph
rya%
fdS.�
Agent's Email
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom nortfon to be comW t..d by th Adta,.ant Pry
I hereby car* that t own propertyadjacentto the above referenced
penntt has described to me, as shown on the attached drawing, the de elopmentfthey ae a proppoosing, q.
descdotion or drawing wtih dimensioris Is a vide this !attar.
l' r�-j�
,lilt % hD0 NOT have Objections lip this proposal. _ I DO have objections to this proposal,
raeneganrent (Dav in wdd wHnl 90 "- ,-- ..,,.a. rwwry cne ".U. UIMIM Of Coasts)
rnetletf to 401 &. Griffin n days of receipt of ttlls nodce. Correspondence stiould be
contacted at (252) 264-390f No � consider � some UOn (f ocan also be
u have been
notified by Certified Mail.
WAIVER SECTION (Chooss e6ly one
I understandthat anY propose pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or
groin must be Sot track a minimum distance Of 19 from my area Of riparian access unless waived by me
(this does not aooly to bulkheads or doreo revetments). (If you Wish to waive the setback, you must ston
the appropriate blank bebw.)
I DO wish to waive somelat of the i5' setback
Stgnafuro ofAdjacetd Rlp\arWrt Proper/(y.t/hvn/er
-OR,
100 NOT wish to wove th ' 16' setback mcgrement (tnifial the blank)
Signature of Adjacent Riparian Property Owner.
TypedlPrinted name of ARPO:
Haling Address of ARPO'00_ C1 ,.
ARPO's email: _J�Zth'•? ffti ' �O's Phonal;
Bate: y J I -A *Waiver is valid for up to one year from ARPO's Signature*
Revised August 2022

N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONMAIVER FORM
CERTIFIED MAIL - RETt tRN RGrFIaT REQ ESTFD or HAND DELIVERYRECEIVED
(Top portion to be completed by owner or their agent)
,(� APR 8 2024
Name of Property Owner. /IQyL /Ce7`QG�
AddrdasofProperty: �In� JP�f G%p!^Se /41le
[�QM-EC
Mailing Address of Owner. /1071 27 L5/
Owner's email: Owners Phone#: ZSZ
Agent's Name: -%i � 1 / Agent Phone#
Agent's Email: _
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
I hereby certify that I own property adjacent to the above referenced property. The individual applying for this
permit has descobed to me, as shown on the attached drawing, the development they are proposing. A.
desainfinnnr effAwinnudfh.-Fti-.
i��lrul h J--ILZhD0 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. Griflfin 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 onlysnel
I understand that any proposed pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or
groin must be set back a minimum distance of 1 T from my area of riparian access unless waived by me
(this does not apply to bulkheads or riprep revetments). (if you wish to waive the setback, you must at
the appropriate blank below.)
I DO wish to waive somefall of the 15' setback
Slgnature of Adjacent Riparian Property Owner
-OR-
I DO NOT wish to waive the IS' setback requirement (Initial the blank)
Signature of Adjacent Riparian Property Owner:ti�/�/
TypediPrinted name of ARPO: Qri- A QS vCi�Gi�r�Y C
Mailing Address of ARPO:
ARPO's email:
ARPO's Phone#:
Date: i i - N- a01 y "waiver Is valid for up to one year from ARPO's Signature*
Revised August 2022

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