49249D - Willis

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3ENERAL PERMIT Previous permit#
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:oastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
/ I Rules attached.
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FARM&HOME CONSTRUCTION 66-456-531 7426 (_
",r DEAN H.RIVENBARK 1
t 204 EA DRIVE 71/L 61 7
WALLACE,E NC NC 28466
(910)285- 489
.4/1#600444eb‘e 19 =V::
W •CE,NORT, •O rA2: ••
Aft A i -/61-- alt
NP
L 3 3000 3 7860 7426
i •
•

• P 'CERTIFIED MAIL - RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
purpose of this form is to provide proper notice to you as an adjacent riparian property owner to the individual or
viduals listed below. The CAMA General Permit application procedures require that applicants provide the Division of
stal Management confirmation that a written statement has been obtained signed by the adjacent riparian property owners
sating that they have no objection to the proposed work or that the adjacent riparian property owners have been notified
ertified mail of the proposed work. Often these forms are submitted to the adjacent riparian property owners by a marine
ractor or other individuals acting as an authorized agent on behalf of the applicant.
s form was sent to you by the following individual or company designated by the applicant as an
horized agent:
horized Agent's Signature Date
le of Individual Applying For Permit:
Tress of Property: -1 14 , , ; &it- .
(Lot or Street#, Street or Road)
(City and County)
-eby certify that I own property adjacent to the above-referenced property. The individual applying for this permit
described to me as shown on the attached drawing the development they are proposing. A description or drawing.
i dimensions. should be provided with this letter.
I have no objections to this proposal.
ou have objections to what is being proposed, please write the Division of Coastal Management, 127
dinal Drive Extension,Wilmington,NC 28405 or call 910-796-7215 within 10 days of receipt of this notice.
response is considered the same as no objection if you have been notified by Certified Mail.
WAIVER SECTION
iderstand that a pier, dock, mooring pilings, breakwater, boat house or boat lift must be set back a
iimum distance of 13' from my area of riparian access - unless waived by me. (If you wish to waive the
lack, you must initial the appropriate blank below.)
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
AilA
r\ _ _ i �� , t, ,„ , _. . . �_ Q► .-,

SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY
• Complete items 1,2,and 3.Also complete A. Signa
item 4 if Restricted Delivery is desired. X / 0 Agent
• Print your name and address on the reverse j ` ❑Addressee
so that we can return the card to you. a e eive by irate ,ame) C. to of Delivery
• Attach this card to the back of the mailpiece,
on the front if space permits. lJ�(LA P ( ,a / --,)-0 � 1
1. Article Addressed to:
D. Is delivery/address different from i em 1? 0 Yes
If YES,enter delivery address below: ❑ No
11 t
7Q‘ (9,-) P*111.-- C)t. ' 6 6.,
C„-_.,(,,,,_cld...._
,Jft 1 I �__ 3. Se ice Type
I � ertified Mail 0 Express Mail
Registered 0 Return Receipt for Merchandise
Z-7_=7 ❑ Insured Mail ❑ C.O.D.
4. Restricted Delivery?(Extra Fee) 0 Yes
2. Article Number CO -�� /� � '�
(Transfer from service label) O `~Y� I`�t� 2 J p/
PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540