68583D - Williams

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: A x W /T M S
Mailing Address:
Phone Number: 2 d 9
Email Address: \vV (L L % A-M S Q 8 2 3 SZ L� Yx
I certify that I have authorized
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAM©A permits
necessary for the following proposed development: /2G4W UiL�
11 1 i
Y� AU yk 1-7(),
at my property located at S' /4l; L Z L? iL
in dAI,l-5LulcJ County.
1 furthermore certify that I 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 with evaluating information related to this
permit application.
Property Owner Information:
Signature
X i 4L/ /I-M 5
Print or Type Name
R(
aUV n a'\.
Title

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to 4L rC— %( I
property located at 2 D q SELL 7 /2 (Name of Property Owner)
(Address, Lot, Block, RoaA etc.)
on _� }l�uJ/C� 8)9-y , inS/U t>S a"% , N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
loc '
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. f y wish to waive the setback, you must initial the appropriate blank below.)
7;z I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
�fJ
Signature
yq-L 1�- x w l L
(Adjac nt Property wrier Information)
s
yf mac,
Signature
Print or Type Name
Print or T e N me
/ GAL / /" ��.r/%/�i /%

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to U �tL 1 s
(Name of Property Owner)
property located at '2 c7 ,j j���L2— � V2
,,11 (Address, LotBlock, Roao etc.)
on kC �� i9� 1 �k C>'( , in eS � C �� 2 I , N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
locati /
___ 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 y u ish to waive the setback, you must initial the appropriate blank below.)
1 do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Propert Owner Information)
Signature
A-L-ix _zv
Print or Type Name
2 , -) GX <'/lF / > TT /)
(Adjacent Property Owner Information)
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Si Lure *
Print or Type NTVe ,-21

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