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N.C. VV1SION OF COASTAL MPk%AGEME%T
AGENT AUTHORIZATION FORM
Date li Ll 9 , b
dame of Property Owner Applying for Permit:
�obtvT Lal►ut Fr«.�y S1+oK5
'.Mailing Address:
37o Fri-�...a�� 51•.�es �eo�
I certify that l have authorized (agent) �,(9���W�% M I- l�c� 1 to act on m�
behalf, for the purpose of applying for and obtaining all CA' tk Permits necessary to
install or construct (activity) Y��' �1Y��3►`�^�
at imy prop", located at)
This certification is valid thru (date)
.* . Lam- // /19/4
Property Owner Signature
Date

ADJAC
W
I hereby certi
,roperty located a
in IClvu1
. (V1
applicant's phoi.....
0 vt kids
ER STATEMENT
BOATHOUSE)
s
TProperty Owner)
, N c- , N.C.
id/or County)
3Zo Jly 51,bVfs izJ
w;l�;hror NC
ie has described to me, as shown below, the development he is proposing at that location, and, I
lave no objections to his proposal. I understand that a pier/mooring pilings / boatlift / boathouse
nust be set back a minimum distance of fifteen feet (IS') from my area of riparian access unless
valved by me. (If you wvish to waive the setback, you must initial the appropriate blank
)elow.)
I do not wish to waive
I do wish to waive that setback requirement.
----------------------------------------- ----------------------------------------------
DESCOPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled In by individual proposing development)
................. ------f___]----;---------------------------------------------e----U«-ner Information) ---
(Information for PropeM Owner Applying (Riparian Property
for Permit) a lDcr r L o ,4e-
Fr�evd $1,+r•es l�ohatdu�Mivs isNt. �zoo
Mailing Address (] Signature
-- - i -- 1 L S1n AV-& �bt d 1, l�,q.� �.4 V, 'L

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSBOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to
FrLe" ll Sl�ov+s 's
(Nam`e o f Property Owner)
iroperty located at Fr 5t -ov45 Rood ,
(Lot, Block, Road, etc.)
,n ICGvu1 (� C1,aNM�1 4".1,,Nn to J"rN5roV%, NG N.C.
(Waterbody) (Town and/or County)
7 Mailin Address: 3Zo F►ry"dl S11br.s izi
applicant's phone #: g io i°I I 5o`t 8 � NC
rujlw►N�toti ,
-ie has described to me, as shown below, the development he is proposing at that location, and, I
lave no objections to his proposal. I understand that a pier/mooring pilings / boatlift / boathouse
nust be set back a minimum distance of fifteen feet (IS') from my area of riparian access unless
,valved by me. (If you wish to waive the setback, you must initial the appropriate blank
)elow.)
I do not wish to waive
4/-1-1 I do wish to waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
(Information for Property Owner Applying
for Permit) (Z a der rL a kue-
Fri,c-A l SVWV l% J4V11Atbw1A1V S At"c
Mailing Address
(Riparian Property Owner Information)
Ra.. i cL 6 a 4 .L T
Signature