57560D - Vanpalla

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I L ' / / L have retained Mark Clements DBA, Clements
Manne Construction c, 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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Pn name
S" at
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Contact information
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DMS10N OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICAT] ONAVAINTR FORM
Name of individual applying for permit: 14e(I a VOLn, VA (,_
Address of propert}': Z�Q �/AO�g 6
I hereby certify that I own property adjacent to the above -referenced propeM,. 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, should be provided with this
letter.)
,AAJI have no objections to this proposal.
If you have objections to what is being proposed, please write the Division of Coastal
Management, 127 Cardinal Drive Extension, Wilmington, North Carolina, 28405 or call (910)
395-3900 within 10 days of receipt of this notice. No response is considered the same as no
obiection if von have been notified by Certified Mail
WAIVER SECI70N
(Does not apply to bulkheads or rip r-AP)
I understand that a pier, dock, mooring pilings, breakwater, boat house, lift or sandbags 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.
1-50
Si re Datc
r ' Print Name
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�1' 1 elephone number with area code

RIP
Name of individual applying for permit: C�eiiP.t'U V, 6- ogJ,-;;,--
Address of property- Q A�� a crig,ed
I hereby certify that I DWm property adjacent to the above -referenced propert},. 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, should be provided With this
letter.)
I have no objections to this proposal.
If you have objections to what is being proposed, please write the Division of Coastal
Management, 127 Cardinal Drive Extension, Wilmington, North Carolina, 28405 or call (910)
395-3900 within 10 days of receipt of this notice. No response is considered the same as no
objection if you have been notified by Certified Mail
WAIVER SECTION
(Does not apply to bulkheads, or rip rap)
I understand that a pier, dock, mooring pilings, breakwater, boat house, lift or sandbags must be
set back a minimum distance of 15' from my area of riparian access unless waived by me. (If you
wisb 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.
Signature Dat:
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Print Narhe
Telephone number with area code

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licant: n%l�
Permit #: �-7 �& O
cribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
id in your Habitat code sheet.
itat Name
DISTURB TYPE
Choose One
TOTAL Sq. Ft.
(Applied for.
Disturbance total
includes any
anticipated
restoration or
temp impacts)
FINAL Sq. Ft.
(Anticipated final
disturbance.
Excludes any
restoration
and/or temp
impact amount)
TOTAL Feet
(Applied for.
Disturbance
total includes
any anticipated
restoration or
temp impacts
FINAL Feet
(Anticipated final
disturbance.
Excludes any
restoration and/or
temp impact
amount)
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MpRiNE CONSTRUC`nON INC
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