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#17 A GE & FILL N. 78441 A B C D ERAL PERMIT „ w Previous permit# ❑Modification ❑Complete Reissue ❑Partial Reissue.. Date previous Permit issued 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 LJ Rules attached. Applicant /Nae 1 �� t�;: Project Location: County ( ! i Addre s ( .> Street Address/ State Road/ Lot #(s) City StateIZip ) Phone # .1' Y .` } E jHa'I — e Authorized enC �. t 11/ � L• Affected CW EW `/�7j/PTA ❑ES ❑PTS AEC(s): OEA' ❑ HHF 'O IH ❑ UBA ❑ N/A Pro ORW: yes/ no PNA yes /rnl� Subdivision Phone #('((�)( Adj. Wtr. Body t Closest Maj. Wtr. Body' UN 0 , .i MEN will C:::�110111 ku VDI ' 'C' . ®.■■■■■..■VARME . ■�l■ 0 N■■■ f.. �I`illl'l►.i �ItOSIF■■■■■■d■■■®■11i■ III SWISS= ME IS Mal ®■■■■■11 Ia -11 IRS it119 0■■■■■®■■■■■■�■■■ii■ illow u■rel IN 1111ri■■■■M Mwwe.w:�. ■■■■■V 11■■■■ ■■■ �iilitlf►I ■Ilf ■■■■1it, ►l■■111■■■ C■■■■ u■■i1■dnA �. ■■■■w! 1C,1■■� 11■w■i■■■oii■H■■ miff ■J�■ M. ■■ ' ■■■Fii ■■■Cal,■ ligb�■i■ ■■■■■■■■■ 1 wf■■i��■■■� ■■l�I� ■■■■� ■■■■��L■iI■ ■■■■■ 1■■1■■E11 HE Ii■■■■■■■■■■®■■■■■■ ■■■■■... a■■■� 111111 MEN ■■ ■■■■■i ii iiENEM=■ice-■■■■ ■■■■i■.r�e■■ 1!i?ili TIME ■■ A■■ �■■■■■ ■■■ ■ ■il■■■■ 1. ■ .ill■■ ®■■■■!li111 �"■1■■■■�►Ibl■� 1i1!61Wi! W19=1ii21111 r'lh �■■■ ■���■ ■■C! op__ � l■us d■■■OEM W ai(9 `Q�iiii■WAWA— It�i Agent or Applicant Printed Name PermitORicer's Printed Name ,t,7;-T� Signature "Please read compliance statement on back of permit" Application Fee(s) Check # i� Date AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION Name of Property Owner Requesting Permit: l 1Mry-1 Mailing Address: Phone Number: Email Address: I certify that I have authorized Q5Gk -(Qaa -"])3a 9510 to act on my behalf, for the purpose of applying for and obtaining all CAMA permits necessary for the following proposed development: Wl ) Ir X S� WAll�ufA..i i Ita�Kf�'plG��orwl at my property located at I of St) ui r1C{ �.1 � C D Y , M % e /J, in r4- County. I furthermore certify that 1 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 IT Signature i Jarw-,,� a b s Print or Type Name Title Date RECEIVED JAN 14 2020 This certification is valid through 5 c:q�da0 DCM-MHD CITY ADJACENT RIPARIAN PROPERTY OWNER STATEMENT I hereby certify that I own property adjacent to 1v n r%nu1 I1L � L-S 's property located at i `l� � , 5Gt,tr+d V u aJ+.ie. (Name of Property Owner) ( (Address, Lot, Block, Road, etc.) on UL rt v �1GYi a in11111 'e-tw-c—( /fit �-U N.C. (Waterbody) (City/Town and/or County) The applicant has described to me, as shown below, 1'le development proposed at the above loca i I have no objection to this proposal. I have objections to this proposal. DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT (Individual proposing development must 11111n descr/ption below or attach a site drawing) WAIVER SECTIOI I I understand that a pier, dock, mooring pilings, boat ran'p, breakwater, boathouse, lift, or groin must be set back a minimum distance of 15' from my ar:3a of riparian access unless waived by me. (if you wish to waive the setback, you must Initial th : appropriate blank below.) I do wish to waive the 15' setback requiremc nt. I do not wish to waive the 15' setback requi ement. (Property Owner Information) (Adjacent Property Ownn+er (Info mmaa,,tion) A1zat9 Print or Type Nla�rpe _ -70 Mad(n Address r N �J �( crty/�ip . Telephone Number/email address Date *Valid for one calendar year after signature* 14 1Iti", (RevisedAul:11-xa14) �0\1N( (©S soun4 Vte4o M DMVNt" U 44, W, 5 00 ��o\jEo a SPA 1 TO ADJACENT RIPARIAN PROPERTY OWNER STATEMENT I hereby certify that I own property adjacent to �L ; wwyy L l y-F t b C 's property located at (Address, Lot, Bh ck, Road, a c.) Oil 7Jc QLzr�r in�? —, ---1 ic�> ,N.C. (Waterbody) (City/Town and/4 County) The applicant has described to me, as shown below, the development proposed at the above location. v� I have no objection to this proposal. i have objections to this proposal. DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT (individual proposing development must fill In descilption below or attach a site drawing) WAIVER SECTIOI;), I understand that a pier, dock, mooring pilings, boat ran p, breakwater, boathouse, lift, or groin must be set back a minimum distance of 15' from my ar a of riparian access unless waived by me. (if you wish to waive the setback, you must initial thy: appropriate blank below.) I do wish to waive the 15' setback requiremr:nt. 1 do not wish to waive the 15' setback requf ement. (Property Owner Information) (AdJa cent Property Owner Information) Si&t re ItWS /4 hh S SIgnG Print or Type Name Prin cr Type Name CPL+LL P�2U 4 TLC * LGC/ 14r G/T� MaIG/JgAddress Mellin/Vd I City/S ate ip City/ %ate/Zi , , b T Telephone Number/email address Telephone umber/email address Date _ Date* �,2014) "Valid for one calendar year after signature* (Revised �u1g.� 2Q2� IpN , -)Imml 1--� Ls irop - j t ©'5 ,Sou r) 4 etj M v"-hF-" C,; ll N e' m 3Z'vl— i JI aECFIVE® JAN 14 2020