68580D - Moyer

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to Move4 's
(Name of roperty Owner)
property located at
on
(Waterbody)
(Address, Lot, Block, Road, etc.)
. in
(City/Town and/or County)
N.C.
The applicant has described to me, as shown below, the development proposed at the above
to iqR.
I have no objection to this proposal.
1 have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(individual proposing development must rill in description below or attach a site drawing)
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, 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.)
do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information) k,�
�i nature
err��'I
ont orType Name '
(Adja ent Pk6perty O er Information)
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ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to A6 r/�F s
(Name QQf Property Owner)
property located at h /t04J. S.4)LUA 45:-r- 0-sh" Cw'�-
(Address, Lot, Block, Road, etc.
on .�C Gt�L� , in SN,hds jrr /1C Z12N6O , N.C.
(Waterbody) (CitylTown and/or County)
The applicant has described to me, as shown below, the development proposed at the above
,locatio�n.
\_ 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 description below or attach a site drawing)
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, (ift, 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.)
1 I do wish to waive the 15' setback requirement.
. I do not wish to waive the 15' setback requirement. ,�� /' �J ksv
(Property Owner Information) (Adjacent Property Owner Information) ,,w�,n
/�?/ - r 1 4 - -.
Si nature Signature d,�
Print or Type Name Print or Type Name
It.-P J s /�.,�r-�•� !� P�-�f-ll' 136 St4tWXeS+ T)n're

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date ! l -%—/ 77
Name of Property Owner Applying for Permit:
Mailing Address:
I certify that I have authorized (agent) (.c9,✓.�A�✓fir�i l O.�ru��� to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity) �,'lf WT�c�,a,rb,
at (my property located at) 160 �;� JfitriMO��
This certification is valid thru (date) %/.9-/'7
J--f""1 %
Property Owner Signature Date

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