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ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PMR/MOORING PILINGS/BOAT1JFT/BDATHOUSE)
4Ai '
I hereby certify that I own property adjacent toA(Name
s
f Property (ironer)
property located at " ""`'w r J Ic
(Lot, Block, Road, etc.)
Oil �tUCP yin V(NnSWtC1e Coles'► ,N.C.
(Wateri)0dy) (Town and/or County) n
Applicant's phone #: �%f0" % y0 Mailing Address: ,�`
He has described to me, as shown below, the development he is proposing at that location, and, l
have no objections to his proposal. I understand that a pier/mooring pilings I boatlift I boathouse
must be set back a minimum distance of fifteen feet 0 5`) from my area of riparian access unless
waived by me. (If you wish to `valve the setback, you must ini 'al 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)
47e1aGXc
(Information for Property Owner Applying
for Permit)
�An SG�lI%t/lC%'t
Mailing Address
7tlf 74 �r
City/state/Lip
2Sq)
Tele hone Number
ature Date
(Riparian Property Owner Information)
eignature
Print or Type Name
7—/— /
Telephone Number
Date

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Division of Coastal Mgt. Habitat impact Computer Sheet
Iicant: l4(V0LYv Permit #: 934-�+b
tribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
id in your Habitat code sheet.
tat 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 ❑ 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 ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
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PAY
TO THE
ORDER OF
J 1 l u. i I y t D
MARITIME BUILDERS; INC. 12-M
910-842-3625
115 E ISLAND DR.
OAK ISLAND, NC 28465-7612
19r
le
Bank ofAmerica J- -��--
ACH R/T 053000198
FOR ''If !�(UCl/tWii,w 1 1 1 t�• � ���.5,1
11�002 248u■ i.an q:inn l 1 or ..
DATE
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