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ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSBOATLIFTBOATHOUSE)
I herebycertify that I own roe adjacent to �5
Y property rtY J r4 -, EEPQ,2 s
(Name of Property Owner)
property located at YwG Jr0U-1 ►eZt> LANpk AG kn
(Lot, Block, Road, etc.)
on NEuJ Ri,lcQ , in �t�1EADS N.C.
(Waterbody) (Town and/or County)
Applicant's phone #: 410 - -_ 9Ss Mailing Address: ii.2 /Yt c it i 1 R 5 f
► LM
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
\�s
� 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)
//a /_vyAg
Mailing Address
Signature

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGS/BOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to SNtico5 4Ft Apr SP©1�i 's
(Name of Property Owner)
property located at 316 V %)L.C.Nci5 LgNp �yA
(Lot, Block, Road, etc.)
on IjEw Rj-4Ek , in SNcAD5 ►= = ky N.C.
(Waterbody) (Town and/or County)
Applicant's phone #: Mailing Address: 11Q WV I CAe -,.-r
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.)
P:�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)
112 07cVlcAP s-;-
Mailing Address
S ignature

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
ael F. Easley, Governor Charles S. Jones, Director William G. Ross Jr., Se
Authorized Agent Consent Agreement
NuT1 N64 x rC)�� G Y'C)C-C10 is hereby authorized to act on my beh;
(Printed Name of Agent)
er to obtain any CAMA permit(s) required for the property listed below. The authorization is limited to
fic activities described in the attached sketch.
kTION OF PROJECT:
"-;LCSy L--6
'ERTY OWNER MAILING ADDRESS:
J1SqLn PHONE NO. g1C: - I!g,AcL!;;))CkR
IORIZED AGENT MAILING ADDRESS:
r'm5yC�y
PHONE NO. -i%CG • - 3y?I
A W

ID Division of Coastal N19t, Habitat Impact Computer Sleet
)plicant: a Permit
t J y
ate:
!scribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
and 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.
bitat 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
temp impacts)
impact amount)
temp impacts)
amount)
l J�
Dredge ❑ Fill ❑ Both ❑ Other ❑
—�&
/ .0 18
Dredge ❑ Fill ❑ Both ❑ Other ❑��
■ Complete items 1, 2, and 3. Also complete
item 4 if Restricted Delivery is desired.
■ Print your name and address on the reverse
so that we can feturn the card to you.
■ Attacli this card to the back of the mailpiece,
or on the front if space permits.
1. Article Addressed to:
SA IZ-A. 5 "EJZNl AV-N
NCkzR,C
D1,4. o;::' >tNGt►.1 � SiE!?diG
17ap mAIL. SgpytC.=- �c
RAcr16H, we aw.99
A. Signature
X ❑ Agent
❑ Addressee
B. Received'by (Printed Name) C;tgof Delivery
1 : Is delivery address d erbntlrorri ftem, ? ❑ Yes
If YES, enter delivery address below: ❑ No
3. Servicelype
,1 Ceffled Mail "t3 Ekpress'Mi
❑ Registered ❑ Return Receipt for Merchandise
❑ Insured Mail ❑ C.O.D.
4. Restricted Delivery? (Extra Fee) ❑ Yes
2. Article Number 7009 0960 0000 6030 9740
(Transfer from serv/ce Iabeo
PS Form 3811, February 2004 Domestic Return Receipt 102595-02•M-1540
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other 0

ANTINORI CONSTRUCTION
145 VIRGINIA LANE
SNEA�910) 327.8460
3475
7
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Bank of America .��
ACH ii(f OMW196
66-19-530
-24?V AUTT101 SIGNA E
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►I'008939110 i:053000 L96l: 0006505 2 L II
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