68590D - Long

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
Name of Property Owner:
Address of Property:
(Lot or Street #, Street or Road, City & County)
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Agent's Name #:✓_ Mailing Address:
Agent's phone #: _(. �2-�L—------•�
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 descri tion or drawin with dimensions. must 0 be rovided with this letter.
ZI have no objections to this proposal. _ I have objections to this proposal.
If you have objections to what is being proposed, you must notify the Division of coastal Management (DCM) in
writing within 10 days of receipt of this notice. Correspondence should be mailed to f27 Cardinal Drive Ext.,
Wilmington, NC, 28405-3845. DCM representatives can also be contacted at (910) 796-72f5. No response is
considered the same as no objection if you have been notified by Certified Mail.
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
wish to waive the setback, you must initial the appropriate blank below.)
I do wish to waive the 15' setback requirement.
^_ 1 do not wish to waive the 15' setback requirement.
(Property Owner Information)
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Pnn or Type Name
Adjacent Property Owner Information)
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Print or Type Name
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Mailing Address

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