79423A_Williford, Marshall_20210908

AGENT AUTHORIZATION FOR LAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit:
Mailing Address: In peMbrakcCifdg-
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Phone Number: 3Z5 " O tC, O
Email Address: 4gent
I certify that I have authorizedSiCiC i Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: 34—?s LF 0t
%wI 0,.-ad
at my property located at I L �?.✓1nbeipk,c Circle
in b1pyja4 County.
1 furthermore certify that / am authorized to grant, and do in fact grant permission to
Division of Coastal Management staff, the Local Permit Officer and their agents to enter
on the aforementioned lands in connection with evaluating information related to this
permit application.
Property Owner Information:
Signature
Print or Type Name
Title
l7 .A /
Date
This certification is valid through 1 i

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ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to r5N l� ► I U &d 's
( e of Propel( �wner)
property located at 111 Pcmbvokc C';;�1� ��1`bn N,
�` (Address Lot, Block, Road, etc.)
on PM 10fbkl.4 e� , in �_ V1git N.C.
(Waterbody) (CityfTown and/or -County)
The applicant has described to me, as shown below, the development proposed at the above
location.
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must rill in description below or attach a site drawing)
31, ` x 1 H ` Soa.-ho "-ce- a,-,d r =+- I4
343 LF o� bulk-I1e-cc(
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.)
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property,oOwfier Inform on)
i iature
Print or� t�yype Name
lt1 Fivvt oroke Circle,
Ma!�ffing Address
--5.&tA+p rg NC.
City/State/Zip
Telephone Number/ email address
Date
*Valid for one calendar year after signature*
(Adjace
r Information)
Signature
Print or T e Name
It�"1 bm LC- N tal-
Maili g Address
c On 1Jc- ;L-143Q
City
Telephoon Numb r/email address
Date*
(Revised Aug. 2014)

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