57521D - Tilley

ADJACENT RIPARIAY PROPERTY OWNER STATE -NMI T
(FOR A .PIERIM0ORI_N%G M.LI%GSIBOATLIFTIBOATHOUSE)
I hereby certify that I own property adjacent tJMX- 4--
(\ame of Property Owner)
property located at CAP-0 4 ,s% A, 9 G IF t-
��(Lot, Block, Road, etc.)
on e� C/t'li4�� in i��4-R..
, S19�J'j ?dW'b07& N.
(Waterbody) (Town 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 si
back a minimum distance of fifteen feet (1 T) 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
I do wish to waive that setback requirement.
-ip w
DESCRIP'
1
,z
i
�NN'G`t-
'ION AND/OR DRAWING OF PROPOSED DEVELOPMEN -T.
(To be filled in by individual proposing development)
-aSf�..0 t 12 X
�Ca p.Tt3�-
If you have objections to what is being proposed, you must notify the Division of Coastal Management (DCM) in v+
within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive Ext. Wilmington,
DCM representatives can also be contacted at [phone].
No response is considered the same as 4to obiection if you have been notified by Certified Mail
(Information for Property Owner/Applicant (Riparian Property Owner Information)
Applying for permit)
Mailing Address Signat
City/State/Zip
Print or Type Na

ADJACENT RIPARLA- PROPERTY OWNER STATEMENT
(FOR A PIER/_.�IOORL•NG PILL--iGSIT OATLI.FTIBOATHOL��SE)
I hereby certify that I own property adjacent tcP
(Name of Property Owner)
property located at C—/2` 4,m-; A X L V6
� �� ��� (L�t Block, Road, etc.)
on , in l 134Vxl r
(iNaterbody) (Town and/or County)
He has described to me, as shown below, the development he is proposing at that location, and, I hai
no objections to his proposal. I understand that a pierlmooring pilings / boatlifft / boathouse must be ;
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 do not wish to waive
I do wish to waive that setback requirement
DESCRIP'
f2 •
ION AND/OR DRAVV-LNG OF PROPOSED DEVELOPMENT:
(To be jdled in by individual proposing development) t
n,,sf�.� t tit.
jL`�l�`
Al Ad FcoAirg
If you have objections to what is being proposed, you must notify the Division of Coastal Management (DCM) in
within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive Ext Wilmington
DCM representatives can also be contacted at [phone].
No response is considered the same as no objection if von have been notified by Certified Mail
(Information for Property Owner/Applicant
Applying for permit)
Mailing Address
(Riparian Property Owner Information)
�, Siena

North Carolina Department of Environment and Natural Resources
Division of Coastal Management
edy Eaves Perdue James K Gregmn Dee
remor Director
AGENT AUTHORIZATION FORM
Date: le " ."2d'" /
e of Property Owner Applying for Permit Name of Authorized Agent for this project:
er's .Mailing Address:
QD e
Agent's Mailing Address:
111 � aox �--
ie Number (q l% 7-% -2_9 q � Phone Number t?��3
tify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
nd obtaining all CAMA Permits necessary to install or construct the following (activity):
T25
property located) at
certification is valid thru (date)

licant: J i� I � +4
>. � f
Permit #: > 7 S�Z I
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 ❑ Ot
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 ❑