57382D - Bond

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ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIERIMOOREIYG PLUNGSBOATLIFTIBOAYZro USE)
I hereby catify that t own property adjacent to V a nr An -ND is
(Name of Property Owner)
property loeated ed
(Lot, Block, Road, etc.)
on in
, N.C.
(Waterbody) (Torun and/or County)
Applicant's ptoae MailingAddress: 1.iko L;dd# eeW
yG
He has described to me, as shown below, the development he is proposing at that location, and, I
have no objections to his proposal. I understand that a pier/mooring pilings / boatlift / boathouse
must be set back a minimum distance of fifteen feet (151 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 not wish to waive
^v�I do wish to waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be, flied in by individual proposine deNeloporent)
(Information for Property Owner Applying (Riparian Property Owner Information)
for Permit)
%JQ N n�rr jet
Mating Address S'
N7J
J/
City/Statc&ip Print or Ifype Name
Telephone Number _ l II elepbone Number

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FORA PIERIMOORING PILINGSBOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to N is
(Name of Property Owner)
property located at --)C) C, L :�! ; M -5
(Lot, Block, Road, etc.)
on Cfl�1NL , in _"D i T , N.C.
(Waterbody) (Town and/or County)
Applicant's phone #: ct+6 ' L.S,5' 4 C&'� Mailing Address: )_h2 1pi
!a A u ;= A)c KyL�
He has described to me, as shown below, the development he is proposing at that location, and, I
have no objections to his proposal. I understand that a pier/mooring pilings / boatlift / boathouse
must be set back a minimum distance of fifteen feet (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 not wish to waive
liw: I do wish to waive that setback requirement.
--------------------------------------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
(Information for Property Owner Applying
for Permit)
L&� noT1 �.1
Mailing Address
(Riparian Property Owner Information)
Signature

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
3el F. Easley, Governor Charles S. Jones, Director William G. Ross Jr., Se,
Authorized Agent Consent Agreement
AME 7 N 7-Z) /ntil is hereby authorized to act on my behz
(Printed Name of Agent)
ar to obtain any CAMA permit(s) required for the property listed below. The authorization is limited to
is activities described in the attached sketch.
LTION OF PROJECT:
Le C:4;c y N
'ERTY OWNER MAILING ADDRESS:
LLACr N C
Yt, t� PHONE NO. 2 /0 `,3 4)0R5.
ORIZED AGENT MAILING ADDRESS:
Vi:?611J1 H L�
PHONE NO.
- - - " A %� ;%

PIL

C Division of Coastal &19t, Habitat Impact Computer Sheet
)plicant: Vadiv, Vv Permit #:
ite:
ascribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
ind in your Habitat code sheet.
bitat 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)
Dredge ❑
Fill ❑
Both ❑
OtherK
13 0
1 p� v
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Other 0

ANTINORI CONSTRUCTION
145 VIRGINIA LANE
SNEADS FERRY, NC 28460
[phone]
BankofAmerica.
ACH R/T053000196
66-19-530
. - _ 7
9160I
E %`/ C
M,
3 /cr. DOLLARS
111009 L6011' 1:0 5 3000 1961: 0006 SOS 2 1990,11
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AUTHORIZED SIGNATUR