71717D - Matthews

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to Jaw 17; cl �L e �) ;
(Name f Property Owner)
property located at � 2 4 AlCh a h h H Q ? r1 _r_
(Address, Lot. Block, Road, etc.)
onC�n►1►1G(_�ia1j�11�hAL — m_W-L✓►1�_�l.��f12y1
(Waterbody) (Cilp%rown and/or County)
NC
The a hcant has described to me, as shown below, the development proposed at the abc+e "lion
I have I'D cb,ection to !his proposal
I have objections to this proposal
DESCRIPTION AND!OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposiny development mus( fill in description below or attach a site drawing)
S .e e 1144a G h -e d.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set back a
minimum distance of 15' from my area of riparian access unless waived by me (If you wash to waive
the setback, you must initial the appropriate blank below)
I do wish to waive the 15' setback requirement.
Ix, I do not wish to waive the 15' setback, requirement.
(Property owner Information)
nature
Print or Type Name S
21"4 N rknnaet Pl�pri
Mailing Address RIM I
l rr< i h tJ C
Te'ephcro NumGer
(A ' cent Pr only Owner Information)
grnWuc , K� � �l�Li�_
'1�.�
Prr�l or ype , tll A S do Cif
ti!al�rng. �re�ssJ
Cr,y/Sree/Lp a
Telephone Nu�{mber
1- )R-l�f

ADJACENT RIPARIAN PR
O
P
ERTY 04NER STATEMENT
C
I he'ety ren,r, rh�r i n:' FroFnr... i d, It e ^!1 it n m .t n rf 7
-
(Naine Qf Property Owner)
properly located at N Lhe h Yl P I H Q�P n u r
�+
(Address Lot, Block, Road, etc.)
onLj7r,vtl 141 r`.I'
(Waterbody) (CityhDwn and/or County)
The applicant has described to me as shown below, the development proposed at the above location
l-
I have 11 JDiec'ian to this proposal
I have objections to this proposal
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin mist be set back a
minimum distance of 15' from my area of riparian access unless waived by me (If you wish to waive
the setback, you must initial the appropriate blank below.)
I do wish to waive the 15' setback requirement.
� I do not wish to waive the 15' setback requirement.
(Property Owner Information) (Adjacent Property Owner Information)
nature
�^A . t1,M-
Print or Type Name
22-4 N ckarinel f(e1Cn Or
Mailing Address p
, I — i n A) L
rty State
(U 1 D'!`iS`�
Telephone Number
2.-(7-?0[3
Dale
L
Signalure
111.ch�� l t _ r.�l.•
Print or Type Name
Mailing Address
crty/stale/Irp
Telephone NumbW
Dore ---
(Revised 6/1"012)

Date Received
Date De sited
Check From (Name
Name of Permit Nolder,
Vendor
Check Number
Check
unt
Permit Number/Comments
Receipt or Refund/Reallocated
Columnf
Colm-2
Column3
Column)
Column5
--mmB
Column?
Column8
Column9
3/i/2019
Adam Matthews M— Order
Adam Matthews
Citizens Alliance Bank
"08278531933
200.00
GP #71717D
PA rc(. 7951