Exempted_Waters, Geneva_19950411

POBOX 776 •PAMLICO COUNTY BUILDING 1NSPECI'IONS\\ BAYBORO, N.C. 28515
[phone]
(After this form is completed by the landowner proposing the project,
a copy is given to his/her adjacent landowners for their consent and
signatures. The forms are then returned, along with a building plan
aqd other applicable required information, to the Building Inspections,-
Office for building permit application/processing.)
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT EPN#
I hereby certify that I own property adjacent'to
f [1D)"),_ Is on .nQ � U uc cJ i �!! cam•
Name of landowner proposing development body of water
in/near Lot# 1,0 of
community Subdivision, if applicable -
Tax Parcel # L 0 off SR Complete description of how to
locate this property:
The proposed project, a and the location has been
described to me as shown in the drawing below and 1 have no objections
to the proposal.
FOR A PIER, CHECK ONE OF THE FOLLOWING:
_ l wish to waive the 15' minimum setback from my riparian access.
I DO NOT wish to waive the 15, minimum setback requirement.
Draw the proposed structure in the space provided below. List the size
of the structure and measured distances from the adjacent property
lines, other structures on the property, and the road, water, etc.
/6
. , 120-2�
r l
printed Name . rd cao 0 0
�ce �%� Date,2-,�6 J,�Signature

1 ' 28515
1 OBOX 77G PAMLICO COUNTY BUILDING INSPECTIONS BAYBURU, N.C.
P (919) 745 38G1
ik r the landowner proposing the project,
(After this form is completed bynsent and
a copy is given to his/her adjacent landowners f wittheir bu lding plan
C - atures. he forms are then returned, along a Building Inspections'
sign applicable required information, to th
amd other rocessing.)
permit application/p
Office for building
ADJACENT RIPARIAN PROPEK'PY OWNER STATEMENT
EPN#
I hereby certify that I own property adjacent to
_' s on �, , .c is
---- body of water
Name of landowner proposing development
i,ot4tVL" 1 0�of
in/near Subdivision, if applicable
community
:. off SR_
— Complete description of how to
'lax Parcel 4P J�-
locate this property:'"
cu�e.,.. 00-
and the location has been
The proposed project, a -_____—
described to me as shown in the drawing below and I have no objections
to the proposal.
FOR A PIER, CHECK ONE OF THE FOLLOWING:
_ l wish to waive the 15' minimum setback from my riparian access.
I DU NOT wish to waive the 15' minimum setback requirement.
hk>,k4r9rir�r4r4rt4et49ck4r,e3r9rYs4tirkd:o2,ketuaYsr4,YYx4r>lex,kxYklded below. List the size
Draw the proposed structure in the space p
l'OV
4 of the structure and measured distances from the adjaent ac water opetcy
ert
lines, other structures on the property, and the road
2-ev
�'
Date.�kr7 Signature
. Printed Name .
s•