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ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORMG PILINGSBOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to ( lT�-'.cny'u:'' 's
(Name of Property Owner)
property located at ;Z-02. 4�1 %C3:S d kc -'
(Lot, Block, Road, etc.)
on AzCYW'hi , in Gi F 1� , N.C.
(Waterbody) own 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. 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.
I do not wish to waive the setback requirement.
j( I do wish to waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
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Letter of agent
1 "d 4�AV,l}-'cr-*� 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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Contact information

Division of Coastal N19t, Habitat Impact Computer Sleet
plicant: � at Permit #: (J 5(Q� Sz
te: M
Scribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
nd in your Habitat code sheet.
TOTAL Sq. Ft.
FINAL Sq. Ft.
TOTAL Feet
FINAL Feet
(Applied for.
(Anticipated final
(Applied for.
(Anticipated final
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
disturbance.
>itat Name
Choose One
includes any
Excludes any
total includes
Excludes any
anticipated
restoration
any anticipated
restoration and/or
restoration or
and/or temp
restoration or
temp impact
tempimpacts)
impact amount)
temp impacts
amount)
1
✓V
Dredge ❑ Fill ❑ Both ❑ Other
■ Complete items 1, 2, and 3. Also complete A. Signature
-item 4 if Regtricted Delivery is desired.
■ Print your name and address on the reverse
so that we can return the card to you. B. Received by (Pn
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
1. Article Addressed to:
w• er-,5cade �cl
❑ Agent
;�Go Addressee
tTL - I /z
D. Is delivery address different from Rem 1? f ❑ Ye:
If YES, enter delivery address below: ❑ No
3. Se Ice Type
j�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) 7010 1060 0000 8472 2459
PS Form 3811, February 2004 Domestic Return Receipt 102595-02-M-1540
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

CLEMENTS MARINE CONSTRUCTION INC
112 CIRCLE DRIVE 910-270-9110
HAN4pSTEAD, NC 28W
365
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