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ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to C q ,) r. ,, R. I>�N
s
(Name of Property Owner)
property located at j, p jo r , 4 J' �✓� r �- `�r� J ,�
on (Address, Lot, Bloc , Road, etc.)
/� tuJ �..J in ,L\S1 ...1 ,�� _(' N.C.
(Waterbody) (City own and/or County)
The applicant has described to me, as shown below, the d Welopment proposed at the above
location.
I have no objection to this proposal.
I have objections to this proposal.
uw;,rur 1 IUN ANDiOR DRAWING OF PROPOSED DEVELOPMENT
(lndlvldual 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 waive the 15' setback requirement.
Information)
r e,
Print or Type Name
4"0 01 i S
Mailing Addre s
e^�iQtZ w/ G 7 PNG
(Adjwwit Information)
GSignature
S,^�ofdAL 011,
Print or Type Name
Mailing Address
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)608
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to a �,rs
_ (Name o Property Owner)
property located at ) lo(?!a ]=c4� �ar„L�
(Address, Lot, Block, Road, etc.)
on LAJ L in 0-k .1751.r.d Al G N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location./
✓✓ 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 waive the 15' setback requirement
Jr-pl?Plerly OwnerInformation)
Print or Type Name /
$`001 L9, a., AI�rT
Mailing Address
(Adjacent Pr perty Owner Information)
Signature * / P.
Print or Type Name
Mailing Addr2ss

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NC Division of Coastal Mgt. Habitat Impact Computer Shee
icant: kC `'
1�
ITATldisturbances for the application.
cribe below he
of measurement found in your
Habitat code shTOTAL
values should match the name, and units
TOTAL Sq. Ft
FINAL
Feet FINAL Feet
for. (Anticipated final
(Applied for.
(Anticipatteded final
disturbance.
(AppliedDis Disturbance disturbance.
DISTURB TYPE Disturbance total
includes any
Excludes any
total includes Excludes any
any anticipated restoration
)itat Name Choose One anticipated
or
restoration
and/or temp
restoration or tempimpact
restoration
temp impacts
im act amount
impacts amount)
temp p
Dredge ❑ Fill ❑ Both ❑ Other
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑
Fill ❑ Both ❑ Other ❑
c��� ', I

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to s
(Name of Property Owner)
property located at
(Address, Lot, Block, Road, etc.)
on in N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above location.
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, breakwater, boathouse, lift, or groin must be set back
minimum distance of 15' from my area of riparian access unless waived by me. (If you wish to wain
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 Owner Information)
Signature
(Adjacent Property Owner Information)
Signature
Print or Type Name
Print or Type Name

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
Name of Property Owner:
Address of Property:
Agent's Name #:
Agent's phone #:
(Lot or Street #, Street or Road, City & County)
Mailing Address:
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 description or drawing, with dimensions, must be provided with this letter.
I 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. Correspondence should be mailed to 127 Cardinal Drive Ext.,
Wilmington, NC, 28405-3845. DCM representatives can also be contacted at [phone]. 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, 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 waive the 15' setback requirement.
(Property Owner Information)
Signature
Print or Type Name
(Adjacent Property Owner Information)
Signature
Print or Type Narne
Mailing Address
Mailing Address