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■ Complete items 1, 2, and 3.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
Article Addressed to:
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Agent
C. Date of Deliver)
1. Is delivery address dMferent from item 1? ❑ Yes
.1f,Y�er�erdelivery dress below: ❑ No .
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MAR 0 4 2021
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9590 9403 0513 5173 3430 28
Certified Mails
Delivery
❑ Certified Mail Restricted Delivery
El Return Receipt for
❑ Collect on Delivery
Merchandise
Z. Article Number (transfer from service label)
❑ Cnuarr r r ,r,,,..., n- ;tricted Delivery
El Signature Confirmation T'
❑ Signature Confirmation
7 019 1640 0000
2 8 7 2 3 6 7 3 Delivery
Restricted Delivery
i&Form 3811. April 2015 PSN 7530-02-000-9053
Domestic Return Receipt

-------------
CER MINA,
UNITED STATES POSIAL
First -Class Mail
Postage & Fees Paid
USPS
Permit No. G-10
• Sender: Please print your name, address, and ZIP+40 in this box*
ev
USPS TRACKING#
9590 9403 0513 5173 3430 28

■ Complete items 1, 2, and 3.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mailpiece,
_or on the front if space permits.
1. Article Addressed
to:
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✓13lrv��l I p `1
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9590 9403 0513 5173 3436 39
9 4rticla Number /Transfer from service label)
7019 0700 0001 6812 7946
PS Form 3811. ADril 2015 PSN 7530-02-000-9053
X
❑ Agent
❑ Addre
�.Oceived by (Printed Name) C. Date of De ive
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D. Is delivery address different from item 17 ❑ Yes
If YES, enter delivery address below: ❑ No
►ECEIVED
I I MAR 0 4 2021
3. Service Type
❑ 41N �� /D
❑ D livery
❑ ertifie ail
❑ Priority Mail Express®
❑ Registered Mail R
O Registered Mail Restricts
Delivery
❑ Certified Mail Restricted Delivery
❑ Collect on Delivery
❑ Collect on Delivery Restricted Delivery
red Mal
;red Mail Restricted Delivery
❑ Return Receipt for
Merchandise
❑ Signature ConfirmationT
❑ Signature Confirmation
Restricted Delivery
rc $500)
Domestic Return Receipt

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UNITED STATES 0O�T�L S RVICE
First -Class Mail
Postage & Fees Paid
USPS
Permit No. G-10
• Sender: Please print your name, address, and ZIP+4® in this box*
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USPS TRACKING#
9590057,3 5175 3436 39

DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
CERTIFIED MAIL - RETURN RECEIPT REQUESTED or HAND DELIVERED
Name of Property Owner:
Address of Property:
Agent's Name #:
Agent's phone #:
(Lot or Street #, Street or Road, City & County)
Mailing Address:
RECEIVED
MAR 0 4 2021
DCM-EC
I hereby certify that I own property adjacent to the above referenced property. The individual
applying for this permit has described to me as shown on the attached drawing the development
they are proposing. A description or drawing, with dimensions must be provided with this letter.
,have no objections to this proposal. I have objections to this proposal.
J P p
If you have objections to what is being proposed, you must notify the Division of Coastal Management
(DCM) in writing within 10 days of receipt of this notice. Correspondence should be mailed to 401 S.
Griffin St., Ste 300, Elizabeth City, NC, 27909. DCM representatives can also be contacted at (252) 264-
3901. No response is considered the same as no objection if you have been notified by Certified Mail
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or groin
must be set back a minimum distance of 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.)
,,e �` - I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
Signature
Print or Type Name
ice PtviiK►I &
Mailing Address ,�1)
R dA.,
23 %-f 1lDI`1`1�3�'
Gify/State/Zip
Telephone Number/Email Address
sllo��
Date
(Adjacent Property Owner f6hU-
Signature *
7TLO.14,
Print or G�Type Name / %
( 0 I 6 L)vi�ic a I u
Mailing Address
IZ4ACr,,A...I/Z ),/,/ /-/1 )/
City/State/Zip
-711 L ZY-V70�
Telephone Number/Email Address
i I Z-7 Z1
Date
"Valid for one calendar year after signature` Revised Jan. 2017

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MAR 0 4 2021
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Feature 1 -
Proposed Pier
Riparian

Currituck
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Currituck County
Aerial Photography (2016
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Currituck County GIS
[phone]
This map should be used for general reference purposes only.
Currituck County assumes no legal liability for the information
www-co.currituck.nc.us/Geographic-information-Services.cfm
shown on this map.

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