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ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIEkV00RING PILINGSBOATLIFT/BOATH/OUSE)
1 hereby certify that I own property adjacent to /+� f''� �-,pd� ,s
1 (Name of roperty Owner)
property located at _ f 2-21 I'V fol
(Lot, Block, Road, etc.)
on 66 ,
� m -- �' --� N.C.
(Waterbody) (Town and)o County)
Applicant's phone #: I — l 2I1VMailing Address: Ary)
Re 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 i boatlift / boathouse
must be set back a minimum distance of fi fteen 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
V I do wish to waive that setback requirement.
DESCRIPTION ANDIOR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
(Information for Property Owner Applying
for Permit)
Mailing Address
CityiSta e/Zip
(Riparian Property Owner Information)
C_
Signature
Print or Type flame

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ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER410ORIVG PXLI-VGSIBOATLIFTIBOATHO USE)
I herebv certif} that I own property adjacent to �dm � _ �V s
--
(Name A Property Owner)
property located at 1D"_
l (Lot, Block, RQad, etc.
or 15t' -- ,4 in t' CJ-� N.C.
(Waterbody) (Town aifdlor County)
He has described to me, as shown below, the cevelopment he is proposing at that location, and; I Iuve
no objections to his proposal. I understand that a pier/mooring pilings l boatlift / boathouse must be set
back a minimum distance of fifteen feet (I 5� from my area of riparian access unless waived by me.
(If you wish to waive the setback, you must initial the appropriate blank below.)
o not wish to waive
I do wish to waive that setback requirement.
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DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
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If you have objections to what is being proposed, you mnst notify the Division of Coastal Management (DCAt7 in writing
within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive Eat.' Wilmington, NC
DC-Ni representatives can also be contacted at [phone]_
No response is considered the same as -no obiection if you have been notirted by Certified Mail
(Information for Property Owner/Applicant
Applying for permit)/J
Mai 1 i ng Address
(Riparian Property Owne UQ�tin)
Signature

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NCDENR
North Carolina Departmeni of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue, Governor James H. Gregson, Director Dee Freeman, Secretary
/— Lli�— Date
Name of Property Owner Applying for Permit:
Ze�' en 'e-
Mailing Address:
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I certify that I have authorized (agent) "/- .-. 45 � i '� �� to act on my
behalf, for the purpose of applying for and
%obtaining all LAMA Permits necessary to
install or construct (actiAty) 406
at (my property located at) �fiZ(`,� r,4,
This certification is valid thru (date) Z,6,;� ^/2-

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C,Division of Coastal N19t. Habitat Impact Computer Sheet
plicant:
0�'1�tiJti 111/// IIIJJJ
te:
Permit
scribe 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] Ot
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t So
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Dredge ❑ Fill ❑ Both ❑ Other ❑
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