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ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIERIMOORING PILINGSIBOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to M,4 rrh r � G �.4!/ ..em s 's
(Name of Property Owner)
property located at T-A ,e P—e,J&- s ,,14 Pfrncel # 097 4-:7!3 O I Z_
(Lot, Block, Road, etc.)
on 1'C U) , in Qcpngi 1S/e- /3fAc4 , 15,eu" , N.C.
(Waterbody) (Town and/or County)
Applicant's phone 0863 Mailing Address: Roaox /S'S<Z
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
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)
(Riparian Property Owner Information)
Mailing Address
Signature

i
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue, Governor James H. Gregson, Director Dee Freeman, Secretary
Date //- 2 1 - J 1
Name of Property Owner Applying for Permit:
M 1frr-A e'o
Mailing Address:
/ocJ% 6 e D ro00hS Ce-.rc-,L r-T
W l µ Sral S't- le" l l C_ % 1/C74
I certify that I have authorized (agent) C' to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity) 1Di oe-L k 1-/ R T—
at (my property located at) # ZS 7 PE D / Z—
This certification is valid thru (date) 6 - /Z—

C Division of Coastal Mgt. Habitat Impact Computer Sheet
olicant:(� ��,,�, Permit
�e.
scribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
nd in your Habitat code sheet.
litat 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)
J W
Dredge ❑ Fill ❑ Both ❑ Otherx
L4,+
I L+4
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 ❑
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 ❑

JOHN R. WEST
DBA WEST DOCKS
1595 CROWN CREEK CIRCLE SW
OCEAN ISLE BEACH, NC 23469
[phone]
DATE
tL -z(-r!
TO THE N VAY -DI V
ORDER OF
.o Dc
FIRS' BANK 16k 1 �s ��'�
OCEAN ISLE BEACH, NOkTH CAROLINA 28469
FOR _mot_ c P LY1 1p 2ru� /
11'000 2 208311' 1:0531045681: 79100 13"'3)0