56511D - Forrest

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ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSBOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to CA0F43,,, ��0� S 's
(Name of Property Owner)
property located at k CAA
(Lot, Block, Road, etc.)
on CAr1P- , in „ .�R; CUTS? , N.C.
(Waterbody) (Town and/or County)
Applicant's phone #: 4 19-399-CC-111 Mailing Address: _6o03i ►)S 1311
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 t i L6�7
ph- �
04 C.C., 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)
603/ 5 f
Mailing Address
(Riparian Property Owner Information)
XC-���1 �o�✓
Signature

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIERIMOORING PILINGSBOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to RnBBY +moo `"fit 's
(Name of Property Owner)
property located at lcn`I 0 �SY
(Lot, Block, Road, etc.)
on 01►%) L— , in CA Y , N.C.
(Waterbody) (Town and/or County)
Applicant's phone #: `19 -3 21- I-C I Mailing Address: GQ31 t_l S 13 k'
Vic!? �o� ? mr- �
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"'A7L I do not wish to waive
N*'% fi (i4- 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)
LAC)/ 05 13nl
Mailing Address
Signature

�r
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
el F. Easley, Governor Charles S. Jones, Director William G. Ross Jr., Sec
Authorized Agent Consent Agreement
aNriN / [)-A—) is hereby authorized to act on my beha
(Printed Name of Agent)
)r to obtain any CAMA permit(s) required for the property listed below. The authorization is limited to
c activities described in the attached sketch.
,TION OF PROJECT:
C/ "PQ C—
a, fsy y5
'ERTY OWNER MAILING ADDRESS:
f) L06 l3 b/
sn t.wI c—&O �1 C-
a.7, -3 PHONE NO. 1j9-39V 60g1
IORIZED AGENT MAILING ADDRESS:
PHONE NO. 9!D "3.j-'7 " 3`12S'
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Division of Coastal Mgt. Habitat Impact Computer Sheet
1icant: 1� °�� Permit #: 5(oS
lo�as , o
cribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
id in your Habitat code sheet.
itat 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 ❑
I
I Lb
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Dredge ❑ FilIX Both ❑ Other ❑
155
5 5
Dredge ❑ Fill ❑ Both ❑ Other
sl� 5
sZs
Dredge ❑ Fill ❑ Both ❑ Other
I
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 ❑

ANTINORI CONSTRUCTION
145 VIRGINIA LANE
SNEADS FERRY, NC 28460
[phone]
PAYTHE n r C ()
ORDER OF: , V J�
MEMO
LOCO bt�se V1 V-`�
Fur re-s� lllfdor-� )
Bank of America.
ACH R/T 053000196
66-19-530
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G�J��AIT�H.RIIIED.1�.IIATIRE
II■0087631I' ':053000L9D: 00065052L9901I'