89286A - Roughton, Clyde

�°"°"" ❑CAMA ❑ DREDGE & FILL Na 89286 A B C D
a 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:
15A NCAC ❑ Rules attached. ❑ General Permit Rules available at the following link: www.d .nc. ov CAMArules
Applicant Name _
Address
City
Phone # ( )
Email
Authorized Agent j, ' ` h „ , d by r l )
Project Location (County): (/,
State t ZIP ' t— Street Address/State Road/Lot#(s) f- k,a
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Subdivision
City t 1,i It I,
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Affected ❑CW ❑TEW ❑PTA ❑DES ❑PTS Adj. Wtr. Body(I\Sri -I,'i f'i�u;:,l (nat�man/unk)
AEC(s): ❑ OEA ❑ IHA ❑ UW ❑ SPIMA ❑ PWS Closest Mal. Wtr. Body
ORW: yes/no PNA: yes/no/-I I I
Type of Project/ Activity
W.
Em's::oa
Floating Platform(s)
Finger pier(s)
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A building permit/zoning permit may be required
Permit Conditions
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❑ 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 Initial)
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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

9
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N.C. OF COASTAL MANAGEENT
ISION
ADJACENT RIPARIANVPROPERTY OWNER NOTIFICATIONIWAIVER FORWEC I V ED
C,,,zFRTIFIED MAIL • RET\I$NB9IGE PT REQUESTED or HAND DELIVERY
(Top portion to be completed by owner or their agent) OCT 0 i 2024
Name of Property Owner:
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DCM—EC
Address of Property:
\31 ' 3c1 SA\o-6o43-V
PRO
, \14 Zi 0Q `\
Mailing Address of Owner:
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Owners email: OILS (Z
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Owners Phone#:
Agent's Name: V tc"q¢.p WA WD Agent Phone#:
Agent's Email: Rt�tlat c�W�c�e\\15®�hnar\ CAm
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
1'00 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.G. Division or 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, 27009. 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 onitrons
I understand that any proposed pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or
groin must be set back a minimum distance of I& from my area of riparian access unless waived by me
(this does ngi ggply tg bWlkhgads or rlprap (eygtM ne ts). (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-
1 DO NOT wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner:
Typed/Printed name of ARPO: A[EX M &(--/9R
Mailing Address ofARPO: , Zo(61 RogtF IF'AMVY bP. )Wb1.0114tAe/0 16i Z31)Z
ARPO's email: AMAt)&A2RC- 44M,40ARPO's Phone#: .7 /a-7 60" (0 9�
Date: L (0 Z0 Z (/ *waiver is valid for up to one year from ARPO's Signature`
If r
Revised August 2022

N.C. DIVISION OF COASTAL MANAGEMENT RECEIVED
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
r EE TIFIED MAIL • RETU13H 139CEIPT REQUESTED or HAND ELELD IVERY OCT 0 7 2024
(Top portion to be completed by owner or thelr agent) ,�/t�l,�IVI/i
Name of Property owner. _Ct_YDE V, D. OA.toeiTilrr
orl -EC
Address of Property: I31 - 139 Sau_6oaT IZt> . Sa%Ls%-\ tllL 7-19 ly
Mailing Address of Owner; Z%$ 6E w-t Cr,".eT -
Owners email: D GCS EP Qol- CO— Owner's Phone#: —1S'l- 6Sk - 39D3
Agent's Name: KIc%AAR.D WA0V1E-t_ Agent Phone#: Z57--'i3S- u109Z
Agent's Email; t�hac dwacid�1115® 1 Co
ADJACENT RIPARLAN PROPERTY OWNER'S CERTIFICATION
(Bottom portion to be completed by the Adjacent Property 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 attached drawing, the development they are proposing. A
1,00 NOT have objections to this proposal. 100 have objections to this proposal.
it you have objections to what is being proposes, you must nonry me rv,c. uivisron or Eoestai
Management (DCM) in writing within 10 days of receipt of this notice. Correspondence should be
mailed to 401 S. Griffin St, Ste, 300, Elizabeth Ci(y, 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 LCttojose 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
(thslgg#�o�aooly tg ¢ulkheada or rloraa revetments). (if you wish to waive the setback, you Mijst lign
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 1S' setback requirement (initial the blank)
i
Signature of Adjacent Riparian Property Owner: e
TypedlPrinted name of ARPO: , OOkA ff I'dg+�%1
('(1
Mailing Address of ARPO: �� CUl I� e-V Vo-.Beard, UA
ARPO's email: I l�, l dae-4+ 3 ®COx, r)OtARPO's Phone#: 75 - Hb3- D198
Date: pa p-1 'waiver is valid for up to one year from ARPO's Signature*
Revised August 2022

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OCT 0 7 2024
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