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CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner:
Address of Property:
(Lot or Street #, Street or Road, City & County)
Applicant phone #: ��� I�.1 S�=5-1 Mailing Address: 5�
I hereby certify that I own property adjacent to the above referenced property. The individual
applying for this permit has described to me as shown on the attached drawing the development
they ar proposing. A description or drawing, with dimensions, must be provided with this letter.
•t I have no objections to this proposal. I have objections to this proposal.
f you have objections to what is being proposed, you must notify the Division of Coastal Management
(DCM) in writing within 10 days of receipt of this notice. Contact information for DCM offices is
available at www.nccoastaimangement.neticontact—dcm.htm or by calling 1-888-4RCOAST. No
response is considered the same as no objection if you have been notified by Certified Mail.
WAIVER SECTION
understand that a pier, dock, mooring pilings, breakwater, boathouse, or lift 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.)
H I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner or on)
V,vZ�
Sin ui'e
Print or Typ6 Name
-3 c
Mailing Address
1. /, /r►n
(Ripari Prop Owner Information)
7
Si ature
Print or Type Name
,70 Z5
Mailing Address
Z _ ,//( 7 C' v e P

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent
to�&aeJ C)e,4 b U ,
s
(Name of Property Owner)
property located at
(Lot, Block, Road, etc.)
on� , in ��� , N.C.
(Waterbody) (Town and/or County)
Applicant's phone #: v Mailing Address: 1 7
/�k
He has described to me, as shown below, the development he is proposing at that location, and, I
have no objections to his proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by property owner proposing development)
l�eJ
RECEI'VED
qfx'p� 15 � SEP 2 9 2011
(Information for Property Owner Applying
for Permit)
-5/7
Mailing Address
:)CM WILMINGTON
-------------- 7
Prope Owner Information)
Signature
�A
r ,
v . l . v ►� +^ t7 �1

C Division of Coastal Mgt. Habitat Impact Computer Sheet
plicant: )Zpr� Zav&-ry Permit #: s-7S ?3
fe:
�/z If///
scribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
ind in your Habitat code sheet.
Atat 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 [I Both ❑ Other ❑
6
Dredge ❑ Fill ABoth ❑ Other ❑
.Y
YI!5
Dredge ❑ Fill ❑ Both ❑ Other
/ e
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 ❑

FOR SECURITY PURPOSES, THE BORDER OF THIS DOCUMENT CONTAINS MICROPRINTINO- ---'
CAROLINA MARINE CONSTRUCTION, INC. 66-456/531
Ph: 910-793-4143
3600-E South College Road, PMB 326
Wilmington, NC 28412
DATE 9 -4S"Z
P AY
TO
ORDTER OF
FIRST BANK
WILMINGTON, NC
MEMO: �/��YZ� � % 7 � �l'�L{�
(�
11■007 L6511■ 1:053 L045681: 199000