69124D - Strachan

N.C. DIVISION OF COASTAL MANAGEMENT
AGEENT AUTHOIRUZATiCM FO"',
V-1
1tiame of propeyt-,, oNyner.Applying for Permit:
Nllailin- Addr--is-
A/
I certfy that I 11ave authorized (agent)
towc
1)ehaff', for the purpose of applying for and obtaining till CAINIA Permits necessanr to
install or• construct- Cacti viz-10
:at (Mv property iocated at)
15- 7-e "
49 0
TbIscertificatiOnis valid thru (date) 1'�-4 1"ras-ij-
bate
pr()perty ()weer Sia gnature

BAND DELIVER
ADJAVIENT RIPATTAIN monaTy
(munA
ongsn& too/
"harekycwify that I.--wn prapany'"adjawntto
of propaty or, nor';
p noperTy 1=1ed va
C,,of, Blocli� -Roaad2
L CIRIZVOW Nov? wc-
COMOMOT
kas a ma, w, shovir, balowtbz devele-nmem he is P.-rapasling a� that i
C,--
Is PwTaUL i lmd.wZY Zh-a*L a pler.1mocdi-4 pillingsiboalB. tj Ust
Must back a munfimilm offfftc+m feet f.1 T) STa ip;xca cTrOhn
ea hlank
t�yi CtL ui a w a1v c t1a e - tl=k, ycn., I aus itwl rw 2 ppr ap ria L
b4m")
not vesh to vmhm
Owner I;ifbrmztIk=!
pi7
(haxmWon or
C4 4 1 9 1-- - N
t ice' & 47 7-- T 1.

F. AND DELIMER
ADJACENT RIPARIAN I'IZUP],RTY 0);VNER STATEMENT
(FOR A PIERMOONNG PILLNUS BOA TZTFTIBO4THOUSE,;
I he eby certify that I own gropers} adjacent to •-�!� Owner')
(Name of Property
property located at ' f �
tLot, Block, Road, etc.)
on — r'�/c .s, in UGC iv.C.
(i3raterbody) (Town andlor County)
33� �iv�aiiian Adds-ess: ;2�^�'�Z �''�/��
h,ppticaut's phone u:_._•._
Lie haz described to tne, as shox'n belos�;, the development he is propusin at that location, and I
have no objections to his pr«lwsal. I ut- ders=and that a pier/mooring pilings i boattift 1 boathouse
must be set bade a rninimum distance of fifteen feet (15`) from my area of riparian access unless
waiv,d by me. (if you wish to waive the setback, You must initial the appropriate blaiik
betvw.)
I do not t'Ash to waive
A
I do wish to t%naive that setback requirement.
";
DESCRIPTION AND/M DRAWI1G OF FRt}F(3SI+:i� T�t:N'I~i.t�l'I4�.1;;��'.
(To be filled in by itzdividual proposing derelopmentl
(Infcirmation for Property owner applying
for Permit)
�3aili�ng-Adtiress���/ .__._.
A,;,. .
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t.;'ttyfState!Ltp
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Sionature
' Print or Type #a;ne

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