57552D - Hughes

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to M r . An phi 's
(Name of Property Owner)
propertylocatedat_ 675 HuLyhes Road
(Lot, Block, Road, etc.)
on M' 11 Crppk ,in Hampstead , PPndPr cn N.C.
(Waterbody) (Town and/or County)
He has described to me as shown below, the development he is proposing at that location,
and, I have no objections to his proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(To be filled in by individual proposing development)
MILL CrC4
re ?tckcx_
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l 1 b h er-i H056 -
X
Signature

Letter of agent
I Mr. Hughes have retained Mark Clements DBA, Clements
Marine Construction Inc, to make application for any and all permits needed to start
construction on the work requested for our property or properties.
By allowing Mr. Clements to make such applications I do understand that this will in no
way relieve me of any obligations to perform all work according to the building codes of
North Carolina, CAMA, DWQ or any other state and or county ordinances.
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Print name
Signature
p — l — (1 Zi date L 5 �-
ontact information

licant:
Permit #: 577j5�Li
:vibe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
id in your Habitat code sheet.
TOTAL Sq. Ft.
FINAL Sq. Ft.
TOTAL Feet
FINAL Feet
(Applied for.
(Anticipated final
(Applied for.
(Anticipated final
tat Name
DISTURB TYPE
Choose One
Disturbance total
includes any
disturbance.
Excludes any
Disturbance
total includes
disturbance.
Excludes any
anticipated
restoration
any anticipated
restoration and/or
restoration or
and/or temp
restoration or
temp impact
temp impacts)
im/pact amount)
temp impacts)
amount)
S
Dredge ❑ Fill ❑ Both ❑ Other
72,TZ�
/01
Dredge ❑ Fill ❑ Both ❑ Other ❑
■ Complete items 1, 2, and 3. Also complete
item 4 if Restricted Delivery is desired.
■ 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:
`5N))AI al CoYb� �}
�-i�jGl ►Jood fie.
A. Signature
❑ Agent
B. Receivkd by (Printed Name) C. Date of Delivery
t I (LEN Z Cd'uTr ( -13- )?-
D. Is delivery address different from item 1? ❑ Yes
If YES, enter delivery address below: ❑ No
3. Se Ice Type
Certified Mail ❑ Express Mail
❑ Registered ❑ Return Receipt for Merchandise
❑ Insured Mail ❑ C.O.D.
4. Restricted Delivery? (Extra Fee) ❑ Yes
2. Article Number
(transfer from service label) 7007 1490 0001 8396 4425
PS Form 3811, February 2004 Domestic Return Receipt 10259"2-M-1540
Dredge ❑ Fill ❑ Both ❑ Other I I I I i
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

CLEMENTS MARINE CONSTRUCTION INC
2613
112 CIRCLE DRIVE 910-270-9110
HAMPSTEAD, NC 29443 / 66-30/531
365
Date
Order he %l/�� ,(%E/L�%C� $
Dollars 6 a,` ;
®First Ci i
Bank
For_.
1:D 5 3 400 3001:00 3 5 3 208 14 58n' 0 2 6 13
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