56512D - Bartholomew

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to r.ZA, 'F>-'wA�D jy�
C tt (Name of Property Owner)
property located at ! $ F o Ad �� 5-i—
(Lot, Block, Road, etc-) on , in �ur i 'L7'(—�S%CgW �11 , N.C.
(WaterbQody) q (Town and/or County)
Applicant's phone #: /�9" l �� `"-2 3 °iling Address: I Q Z/ F a A00-
F�
2a [ N ire- 4--,4� k,c_ .
Z?567
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)
(Information for Property Owner Applying
for Permit)
Mailing Address
City/State/Zip
N^P
(Riparian Property Owner Information)
e�
Signature
Print or Type Name

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSBOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to r;- e �- i3 a rho I o )y eL..,'s
{�
(Name of Property Owner)
property located at Q 3 Y 8'zo-4J try P
(Lot, Block, Road, etc.)
on , in U w \ l N 5 J49 N.C.
(Waterbody) ('Town a d or County)
Applicant's phone #: 9 /Mailing Address: iy
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 MR)
iedmoorin ilings / boatlift /boathouse
must be set back a minimum - distance o_f fifteen feet from my area of rip an access unless
waved by me. Of you wish to waive the setback, you most initial 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)
�--. (6uaf
IS �ar�P
l"'`" / , K k.,,t
(Information for Property Owner Applying
for Permit)
Mailing Address
(Riparian Property Owner Information)
r i Signature

PIMA
A�
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue, Governor James H. Gregson, Director Dee Freeman, Secretary
Date
Name of Property Owner Applying for Permit:
f
Mailing Address: /
I certify that I have authorized (agent) �n %� /'��°S to act on my
behalf, for the purpose of applying for hod obtaining all CAMA Permits necessary to
install or construct (activity) kv11<A P4Cl, ��o
at (my property located at) I
This certification is valid thru (date)_
Property Owner Signature

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Division of Coastal Mgt. Habitat Impact Computer Sheet
)licant:
iwd Permit #: qP S(Vs)
ie:
1 yi
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 fina
disturbance.
Excludes any
restoration and/(
temp impact
amount
Dredge ❑ Fill1A Both ❑ Other ❑
g(p
Dredge ❑ Fill Both ❑ Other ❑
L13
Li
Dredge ❑ RIX Both ❑ Other ❑
Ir—
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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B & B MARINE CONSTRUCTION
PH- 910-540-5135
9045 9TH STREET
SURF CITY, NC 28445
Pay to the---- of
to) First federal
HAMPSTEEAQP
D, NC 288443
FOR Lll,.ar ,-7 j g? I O n—)
Date—ZLL-----
101
87-7194
0
11200105311' 1: 253 2? 1945i:58060070361IN �—