69097D - New

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: tonkr�+ OLS H(
Mailing Address:
Phone Number:
Email Address:
I certify that I have authorized
G/V cue
S -7e Q -
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: N'llj Ac-c-L
at my property located at _ I i 1( C
in.. i Do S1 ()Lz J County.
I furthermore certify that l am authorized to grant, and do in fact grant permission to
Division of Coastal Management staff, the Local Permit Officer and their agents to enter
on the aforementioned lands in connection,*th evaluating information related to this
permit application.
Property Owner Information:
(o w K.,q�: C-"*i sc l
Print or Type Name
1 c ,v--r- `.W- 6 v
Title

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to Nx. 7 0-0 's
(Name of Property Owner)
F-
property located at _F C L;, VA �V; (lr-ly-cle
(Addres , Lot, Block, oad, etc.)
on _ __ cN� -� 1�. P� , in . rr M � Gyp N.C.
(Waterbody) (City/Town n /or County)
The applicant has described to me, as shown below, the development proposed at the above
to ti
I have no objection to this proposal.
I 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.)
I do wish to waive the 15' setback requirement.
1 do not wish to waive tbq 15' setback requirement.
(Property Owner Information
(Adjacent Property Owner Information)
b�0.
Signature
N.p ,n "-(A VY\A<z Z-S
Print or Type Name
1",C4 Gv / 44,6 i0co lc c
Print or Type Name
1�1-0 " , t 1 C_P-

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to t--4 . i . \? . H �:., A 's
` Y�(Name of Property Owner)
property located at � �t� � � �. S� ��
(Address, Lot, Block, Road, etc.)
on _ S 't cM-z Y , in r\ " c-cA'S 6" S N.C.
,.Vaterbo y) (City/Town n /or County)
The applicant has described to me, as shown below, the development proposed at the above
to
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, 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.
I do not wish to the 15' setback requirement.
(Property Owner71nform3La/�'o ( 'acen r e O ner Information)
Q
Signature S,*Ture* T CA K0Qt
Print or Type Name PH or Type Name
boa w, t_L_V,,�oo►c C

Ij bing rnup,
118 Club House Rd, Sneads Ferry, NC 28460 New River Plantation Community
Clubhouse/Pool HOA
118 Clubhouse Road
Sneads Ferry NC, 28460
25 m
02017 HERE
Xs
l
b x / s' Lcti