68541D - Szymanki

CERTIFIED MAIL - RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
Name of Property Owner:
Address of Property
IT5a --T-5
(Lot or Street #, Street or Road. City & County) / /� j
Agent's Name #:PaL.Ayie&/vC\ Mailing Address:.�4 (t�q t J3bbIkeS/)&—L
Agent's phone # 5Ll 0_ (4 Ll 2, ^� p kV . I v t �6P-2
5 hallop-k16 fc,n5
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 descrttion or drawim with dimensiorn must be oroykW with Oft teller
14— 1 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. Contact information for DCM offices is
available at http://www.nccoastaimana-gement.netlweb/cm/staff-listinci orby calling 1-888-4RCOAST.
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, boat ramp, breakwater, boathouse, or lift 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 waive the 15' setback requirement.
(Property-(�wner Information} i i errtty O nfo
Signature — Y
J1�8 52�M905�
Print or Type Name
1� b e,4i A-ve.
rnGq. Lr,
Print or Type Name
AD 66X_ 0�9
Mathng Address
Maiiing Address

CERTIFIED MAIL - RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner:
Address of Property:
(Lot or Street #, Street or Road, City & County)
11
Agent's Name #: I f� ���,/� Mailing Address:
Agent's phone # q/U 5Ll0 `t 41 Z��
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 draw!n,_ _'he J-v?irxcment
they are proposing. A
401000ilh Its A
VAN& 10 &VANWbM bO SMUNIM-t h ON met.
X- 1 have no objections to thii proposal. I have objections to thu 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. Contact information for DCM offices is
available at http://www.nccoastalmanayement.net/web/cm/staff-listing or by calling 1-888-4RCOAST.
No response is considered the same as no objection if you have been noted by Certirred Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, or lift 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.
X I do not wish to waive the 15' setback requirement.___—_
(Property Owner Information)
Signature
I U� Zq
Prim or Type Name
;,�� 1►�J1fie_
a }er Fri
Print r;r Type Name
Lb 6ox 3 )9
f t,4—

.......... o�
I rnT
d

NC Division of Coastal Mgt. Habitat Impact Comi
Applicant: 0.1n-q Sz ��v�s , �
Date: I Q /a /Z" %
Describe below the HABITAT disturbances for the application.
All values should match the name, and units of measurement found in your Habitat code sheet.
TOTAL Sq. Ft.
FINAL Sq. Ft.
TOTAL Feet
FII
(Applied for.
(Anticipated final
(Applied for.
(Ar
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
dis
Habitat Name
Choose One
includes any
Excludes any
total includes
Exi
anticipated
restoration
any anticipated
res
restoration or
and/or temp
restoration or
ten
ternimpacts)
impact arnount
ternimpacts)
arr
Dredge ❑ Fill ❑ Both ❑ Other
Z
V
C
Dredge ❑ Fill ❑ Both ❑ Other
1
O
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge 0 Fill ❑ Both ❑ Other ❑

■ Complete Rems 1, 2, and 3.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
1. Article Addressed to:
EJ9e<
vo Q ox 3l9
A. Signature
X ❑ Agent
❑ Addressee
B. Received by (Printed Name) C. Date of Delivery
� -�� �. y
D: Is delivery address different from item 1? ❑ Yes
If YES, enter delivery address below: p No
3. Service Type
❑ Priority Mail Express®
II I
IIIIII
III
II
I II
III
I
IIIIIII
I I I
III
Adult Signature
❑Registered Mail -
Adult Signature Restricted Delivery
Certified Mail®
❑ Registered Mail Restricted
Delivery
9590 9402 1911 6104 9123 02
ertified Mail Restricted Delivery
❑ Return Receipt for
❑ Collect on Delivery
Merchandise
2. Article Number (Transfer from service label) I
❑ Collect on Delivery Restricted Delivery
❑ Signature Confirmation —
7 015 1520 0003 2854 5143
loll
vlail Restricted Delivery
❑ Signature Confirmation
Restricted Delivery
PS Form 3811, July 2015 PSN 7530-02-000-9053
Domestic Return Receipt
■ Complete items 1, 2, and 3.
❑ Agent
1 A. rirLSA4�
■ Print your name and address on the reverse
so that we can return the card to you.
X ❑ Addressee
-
B R ed by (Printed Name)
C. Date of Delivery
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
P A, 44
C
1. Article Addressed to
LL`YES,
i f -?a—WW addredi a item 1? ❑Yes
enter delive dr low: ❑ No
jg (�
3. Service Type A Priority Mail Express®
Adult Signature
Rgsered Mail**
I
I
I I
II III
I I
I II
I I
I
IIIIII
I
I I
I I
I
Adult R
`ve❑❑
Regature
tryed Mail Restrictedd
9402 1911 6104 9122 9
Ctiffed MJ
Ml Rest-� eery
Derted
❑ Return Receipt for9590
❑ Collect on Delivery
Merchandise
2. Article Number (transfer from service lahan
❑Collect on Delivery Restricted Delivery
Ball
❑ Signature ConfirmationT"^
❑ Signature Confirmation
7 015 1520 0003 2854 5136
ail Restricted Delivery
Restricted Delivery
PS Form 3811, July 2015 PSN 7530-02-000-9053
Domestic Return Receipt