Strickland, Jan 84337C

'�aFtourp 9�❑CAMA ❑ DREDGE & FILL N4? 84337 A B C ' o
0
y =GENERAL PERMIT Previous permit ermit issued
❑ New ❑ Modification ❑ Complete Reissue ❑ Partial Reissue
As authorized by the State of North Carolina, Department of Environmental Quality and the Coastal Resources Commission in an area of environmental concern pursuant to:
s
Rules attached. ❑ General Permit Rules available at the following link: www.deq.nc.¢ov/CAMArules
15A NCAC ❑
Applicant Name Authorized Agent
Address Project Location (County):
City I State ZIP Street Address/State Road/Lot #(s)
Phone #
Email " " Subdivision
City ZIP
Affected ❑ cW ❑ EW ❑ f PTA ❑ ES ❑ PTS Adj. Wtr. Body ✓ (nat/man/unk)
AEC(s): ❑ IDEA ❑ IHA ❑ UW ❑ SPIMA ❑ PWS Closest Mal. Wtr. Body
ORW: yes/no PNA: yes/no'
Type of Project/ Activity 1Q
Shoreline Length'jllls%
Access Length -
Pier (dock) length
Fixed Platform(s)
Floating Platform(s)
Finger pier(s)
Total Platform area
Groin length/#
Bulkhead/ Riprap length -
Avg distance offshore - -- ` -
Breakwater/Sill _ "" -
Max distance/ length E
Basin, channel
Cubic yards i
Boat ramp I j
Boathouse/ Boatlift
m
Beach Bulldozing
Other
! i.
SAV observed: yes o
i
Moratorium: n/a yes no - T
Site Photos: yes no { -
Riparian Waiver Attached: yes no
A building permit/zoning permit maybe required by: ^`" t �j (� / T-1 j
Permit Conditions f /
i
(Scale: )
❑ TAR/PAM/NEUSE/BUFFER (circle one)
❑ See note on back regarding River Basin rules
❑ See additional notes/conditions on back
I AM AWARE OF STATUTES, CRC RULES AND CONDITIONS THAT APPLY TO THIS PROJECT AND REVIEWED COMPLIANCE STATEMENT. `, (Please Initial)
Agent or Applicant PRINTED Name Permit Officer's PRINTED Name
Signature "Please read compliance statement on back of permit" Signat re
vg j..�
Application Fee(s) Check #/Money Order Iss iAg Date Expiration Date

Statement of Compliance and Consistency
This permit is subject to compliance with this application and permit conditions. Any violation of these terms may
subject the permittee to a fine or criminal or civil action; and may cause the permit to become null and void.
This permit must be on the project site and accessible to the permit officer when the project is inspected for
compliance. The applicant certifies by signing this permit that: 1) prior to undertaking any activities authorized by this
permit, the applicant will confer with appropriate local authorities to confirm that this project is consistent with the
local land use plan and all local ordinances, and 2) a written statement from the adjacent riparian property owner(s)
has been obtained, or proof of delivery of certified mail notification of the adjacent riparian property owner(s).
The State of North Carolina and the Division of Coastal Management, in issuing this permit under the best available
information and belief, certify that this project is consistent with the North Carolina Coastal Management Program.
River Basin Rules Applicable To Your Project:
1-1 Tar - Pamlico River Basin Buffer Rules 1-1 Neuse River Basin Buffer Rules
If indicated on front of permit, your project is subject to the Environmental Management Commission's Buffer Rules
for the River Basin checked above due to its location within that River Basin. These buffer rules are enforced by the
NC Division of Water Resources. If you have any questions, please contact the Division of Water Resources at the
Washington Regional Office (252-946-6481) or the Wilmington Regional Office (910-796-7215).
Notes/Additional Permit Conditions:
Please ensure all debris associated with the removal or construction of the permitted development is contained within the authorized
project area and disposed of in an appropriate upland location.
Division of Coastal Management Offices
Morehead City Headquarters
400 Commerce Ave Morehead City, NC 28557
252-808-2808/ 1-888-4RCOAST Fax: [phone]
(Serves: Carteret, Craven — south of the Neuse River, Onslow
Counties)
Elizabeth City District
401 S. Griffin St. Ste. 300
Elizabeth City, NC 27909
252-264-3901
(Serves: Bertie, Camden, Chowan, Currituck, Dare, Gates, Hertford,
Pasquotank and Perquimans Counties)
Washington District
943 Washington Square Mall Washington, NC 27889
252-946-6481
Fax: [phone]
(Serves: Beaufort, Craven — north of the Neuse River, Hyde, Pamlico,
Tyrrell and Washington Counties)
Wilmington District
127 Cardinal Drive Ext. Wilmington, NC 28405-3845
910-796-7215
Fax: [phone]
(Serves: Brunswick, New Hanover and Fender Counties)
http://portal.ncdenr.org/web/cm/dcm-home Revised 6/01/2021

o �°jCOAR4eLN❑CAMA El DREDGE & FILL N9 84337 A B c D
y�
erm
Previous p
Z - GENERAL PERMIT Date previous Ipermit issued
❑ New ❑ Modification ❑ Gomplete Reissue ❑ Partial Reissue
As authorized by the State of North Carolina, Department of Environmental Quality and the Coastal Resources Commission in an area of environmental concern pursuant to:
I SA NCAC ❑Rules attached. ❑ General Permit Rules available at the following link: www.deq.nc.gov/CAMArules
Applicant Name
Authorized Agent
Address
Project Location (County):
City State
ZIP
Street Address/State Road/Lot
#(s)
Phone # ( )
Email
Subdivision
City
ZIP
Affected ❑ CW ❑ EW
❑ PTA
❑ ES ❑ PTS
Adj. Wtr. Body
(nat/man/unk)
AEC(s): ❑ OEA ❑ IHA
❑ UW
❑ SPIMA ❑ PWS
Closest Maj. Wtr. Body
ORW: yes/no PNA: yes/no
Type of Project/ Activity
(Scale: )
Shoreline Length
Access Length
Pier (dock) length
Fixed Platform(s) ..,
i
Floating Platform(s)
.
--
I
—
I
--
-
--
Finger pier(s) .. ._-_
Total Platform area
Groin length/#
I
Bulkhead/ Riprap length
-
_ ......-
Avg distance offshore
-
-
Breakwater/Sill
_
Max distance/ length
Basin, channel
a...
Cubic yards
Boat ramp
Boathouse/ Boatlift
j
Beach Bulldozing
-
Other
I
SAV observed: yes no
Moratorium: n/a yes no
1
"
Site Photos: yes no
_
-
-f-
Riparian Waiver Attached: yes no
m
A building permit/zoning permit may be required by:
TAR/PAM/NEUSE/BUFFER (circle one)
Permit Conditions
❑ See note on back regarding River Basin rules
❑ See additional notes/conditions on back
I AM AWARE OF STATUTES, CRC RULES AND CONDITIONS THAT APPLY TO THIS PROJECT AND REVIEWED COMPLIANCE STATEMENT. (Please Initial)
Agent or Applicant PRINTED Name
Permit Officer's PRINTED Name
Signature "Please read compliance statement on back of permit"
Signature
f
Application Feels)
Check #/Money Order
Issuing Date
xpiration Date

Statement of Compliance and Consistency
This permit is subject to compliance with this application and permit conditions. Any violation of these terms may
subject the permittee to a fine or criminal or civil action; and may cause the permit to become null and void.
This permit must be on the project site and accessible to the permit officer when the project is inspected for
compliance. The applicant certifies by signing this permit that: 1) prior to undertaking any activities authorized by this
permit, the applicant will confer with appropriate local authorities to confirm that this project is consistent with the
local land use plan and all local ordinances, and 2) a written statement from the adjacent riparian property owner(s)
has been obtained, or proof of delivery of certified mail notification of the adjacent riparian property owner(s).
The State of North Carolina and the Division of Coastal Management, in issuing this permit under the best available
information and belief, certify that this project is consistent with the North Carolina Coastal Management Program.
River Basin Rules Applicable To Your Project:
F] Tar - Pamlico River Basin Buffer Rules F-1 Neuse River Basin Buffer Rules
If indicated on front of permit, your project is subject to the Environmental Management Commission's Buffer Rules
for the River Basin checked above due to its location within that River Basin. These buffer rules are enforced by the
NC Division of Water Resources. If you have any questions, please contact the Division of Water Resources at the
Washington Regional Office (252-946-6481) or the Wilmington Regional Office (910-796-7215).
Notes/Additional Permit Conditions:
Please ensure all debris associated with the removal or construction of the permitted development is contained within the authorized
project area and disposed of in an appropriate upland location.
Division of Coastal Management Offices
Morehead City Headquarters
400 Commerce Ave Morehead City, NC 28557
252-808-2808/ 1-888-4RCOAST Fax: [phone]
(Serves: Carteret, Craven — south of the Neuse River, Onslow
Counties)
Elizabeth City District
401 S. Griffin St. Ste. 300
Elizabeth City, NC 27909
252-264-3901
(Serves: Bertie, Camden, Chowan, Currituck, Dare, Gates, Hertford,
Pasquotank and Perquimans Counties)
Washington District
943 Washington Square Mall Washington, NC 27889
252-946-6481
Fax: [phone]
(Serves: Beaufort, Craven — north of the Neuse River, Hyde, Pamlico,
Tyrrell and Washington Counties)
Wilmington District
127 Cardinal Drive Ext. Wilmington, NC 28405-3845
910-796-7215
Fax: [phone]
(Serves: Brunswick, New Hanover and Pender Counties)
http://portal.ncdenr.org/web/cm/dcm-home Revised 6/01/2021

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: 71� S+vtJ4.4-d
Mailing Address: � q feouvs, tj1'1 U r
Phone Number:
Email Address: I' (�(akd C�LYIc �Gam
I certify that I have authorized Ayw,� 06-38
Agent 1 Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: 6 'X 2,0 " F1,0,V-1,1V6
VoGK At,o 3 /2 / (,+�C/,/,o Y
at my property located at �q Q@aK6h U&I
in C-Z41-CeFr County.
i furthermore certify that I 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.
9-0
ar\� P6 h d
Print or Type Name
OWNEr�
Title
12,
Date
This certification is valid through / I �o I ZoZ Z,

_�
c
y

N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
CERTIFIED MAIL RETURN RECEIPT REQUESTED or NAND DEL V RY
(Top portion to be completed by owner or their agent)
Name of Property Owner. V ah S E G
Address of Property: /�(S( Pea iS d-)A
Mailing Address of Owner. p !�
Owner's email: 010 Owners
Phone#:
Agents Name: �
/y�46 �t Agent Phone#:
��
Agent's Email: l" /ebhad G
. Go,y+
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
Bottom portion to be completed by the Adjacent Property Owner)
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 wit(t this letter.
�-- I DO NOT have objections to this proposal. I DO have objections to this proposal.
ff you have objections to what is being proposed you In notify the N.C. Division of Coastal
Management (DCM) in writing within 10 days of receipt of this notice. Correspondence should be
mailed to 400 Commence Ave., Morehead City, NC 28557. DCM representatives can also be contacted
at [phone]. No response is considered the same as no objection if you have been notified by
Certified Mail.
WAIVER SECTION
I understand that any proposed 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
(this does not apply to bulkheads or riprap revetments). (If you wish to waive the setback, you must sia- n
the appropriate blank below.)
I DO wish to waive some/all of the 15' setback
Signature of Adjacent Riparian Property Owner
-OR- Tr -.—
I do not wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner: �-oALL UD711,
OCLLI
Typed/Printed name of ARPO:
Mailing Address of ARPO: (O ) � �[-� l � <— �U ' - ►� v WI-T- Ay I ! e �l._..
ARPO's email -TYCU-04,�? SC t �C V S !G'W O's Phone#: 2 - 9 �ZQF) S
Date: I "waiver is valid for up to one year from ARPO's Signature"
Revised May 2021

f

N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
CERTIFIED MAIL • RETURN RECEIPT REQUESTED or HAND DELIVERY
(Top portion to be completted /b�yi
Property Owner. owner or their agent)
Name of P Ja k Sty e-
Address of Property: 0ZS
7eak�U-'A C- r
Mailing Address of Owner: 0� 1 ¢ 0. t a � ' " �&+ ki(`
Owner's email:)Os�Ot (ttd�i'4i�. 'Ownere� s Phone# q10 ' 306 • 3ary
Agent'sName: A v W6 of e Agent Phone#: Z s 2
Agent's Email: iit=hf7a4ciG RU /�����• °�''^
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom portion to be completed by the Adjacent Prouertv Owner)
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. 6
descriation or drawing. with dimensions, must be provided w4h this letter.
`3 I DO NOT have objections to this proposal. I DO have objections to this proposal.
If you have objections to what is being proposeat; you must notify the N.C. Division of Coastal
Management (DCAI) in writing within 10 days of receipt of this notice. Correspondence should be
mailed to 400 Commerce Ave., Morehead City, NC 28557. DCM representatives can also be contacted
at [phone]. No response is considered the same as no objection if you have been notified by
Certified Mail.
WAIVER SECTION
I understand that any proposed pier, dock, mooring pilings, boat ramp, breakwater, boathouse, Nft, or
groin must be set back a minimum distance of 15' from my area of riparian access unless waived by me
(this does not apply to bulkheads or riprap revetments). (If you wish to waive the setback, you must sign
the appropriate blank below.)
I DO wish to waive some/all of the 15' setback
Signature of Adjacent Riparian Properly Owner
.OR -
I do not wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner: �� 1'
1
Typed/Printed name of ARPO: P(1 '4' e
Mailing Address of ARPO: n
ARPO's email: �� 2�t,�'tS_ � t s'� C r rA PR O s Phone#: 91 -- 3a1- a5 K6
Date: _] I I I-L_ 2 i "waiver is valid for up to one year from ARPO's Signature'
Revised May 2021

IrwPose-D
' Tifo&5fD

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: 71
Mailing Address: as q eeou-& m �l v
0 eto,Poy--� 0 L 2Y5 � LD
Phone Number:
Email Address:
I certify that I have authorized
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: b /'` 20 � rG©'e —/, NG
Voe-k AND 3 i2' ��W��✓a `
at my property located at ��� Qea V�iSh Cil NQ NL 25��
in C-.104i CIeFr
County.
l furthermore certify that I 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.
Uh l% t, %- 6 h d.
Print or Type Name
ohwe-t f
Title
Date
This certification is valid through i I '�y I Zo Z ZI

N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
CERTIFIED MAIL RETURN RECEIPT REQUESTED or HAND DEL V RY
(Top portiontto be completed by owner or their agent)
5—
Name of Property Owner. �J a ✓
Address of Property: _ � e a is d-)'1 C r
Mailing Address of Owner. _ J �p
Owner's email,: NS1 i^t r lU c� qq McuOwne s Phone#:
/v7ji �,agent Phone#: 25 Z
Agent's Name: / 2 r ee
Agent's Email: tie.h,6dd
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom portion to be completed by the Adjacent Prouerty Owner)
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.
imensions must be provided with this fetter.
J C- — I DO NOT have objections to this proposal. I DO have objections to this proposal.
If you have objections to what is being proposed you must notify the N.C. Division of Coastal
Management (DCM) in writing within 10 days of receipt of this notice. Correspondence should be
mailed to 400 Commerce Ave., Morehead City, NC 28557. DCM representatives can also be contacted
at [phone]. No response is considered the same as no objection if you have been notified by
Certified Mail.
WAIVER SECTION
I understand that any proposed pier, dock, mooring pilings, boat ramp, breakwater, boathouse, tilt, or
groin must be set back a minimum distance of 15' from my area of riparian access unless waived by me
(this does not apply to bulkheads or riprap revetments). (if you wish to waive the setback, you must sign
the appropriate blank below.)
I DO wish to waive some/all of the 15' setback
Signature of Adjacent Riparian Property Owner
-OR-
I do not wish to waive the 16 setback requirement (initial the blank)
Signature of Adjacent Riparian Property
ty jO�wne
Typed/Printed name of ARPO: 'aC
Mailing Address of ARPO: (O-J i Ce
VV ' v.I l I e_ �Jc.
ARPO's email: SC t �e +S 6WO's Phone#:
Date: "waiver is valid for up to one year from ARPO's Signature"
Revised May 2021

i

N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONfWAIVER FORM
CERTIFIED MAIL - RETURN RECEIPT REQUESTED or HAND DELIVERY
(Top portion to be completed by owner or their agent)
Name of Property Owner.
Address of Property: a1S� g pea VS � � r
Mailing Address of Owner t I e 0.t-S "'^'t'�
Owner's email: lam �K'r`" Wtd qql`"' �Q' Owner eOs Phone* "110 ' S hP 3aro
.r/J—
Agent's Name: Avg N(a Agent Phone#: Z5 2 -k5_ y?7F
Agent's Email: LJeb!laid c v
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom portion to be completed by the Adjacent Property Owner)
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 drawina with dimensions, must be provided with this letter.
I DO NOT have objections to this proposal. 100 have objections to this proposal.
If you have objections to what is being proposed you must notify the N.C. Division of Coastal
Management (DCII9 in writing within 10 days of receipt of this notice. Correspondence should be
mailed to 400 Commerce Ave., Morehead City, NC 28557. DCM representatives can also be contacted
at [phone]. No response is considered the same as no objection if you have been notified by
Certified Mail.
WAIVER SECTION
I understand that any proposed pier, dock, mooring pilings, boat ramp, breakwater, boathouse, Lift, or
groin must be set back a minimum distance of 16 from my area of riparian access unless waived by me
(this does not apply to bulkheads or riprap revetments). (If you wish to waive the setback, you must sign
the appropriate blank below.)
I DO wish to waive some/all of the 15' setback
Signature of Adjacent Riparian Property Owner
-OR-
I do not wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner. ,.�„�xr,/lG
Typed/Printed name of ARPO: � s
Mailing Address of ARPO:
ARPO's email: �etLeI Ltok eC r�lA PRPR O s Phone#: 25�_- 3q -a! 5 K6
Date: _I I 12 �_ Z 'waiver is valid for up to one year from ARPO's Signature'
Revised May 2021

IrrwPo--D
Zb` 6 7'
'x l 2 ' %ZA►1P
QxiqIN6

N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONtWANER FORM
CERTIFIED MAIL • RETURN RECEIPT REQUESTED or HAND DELIVERY
(Top portion to be completed by owner or their agent)
Name of Property Owner. avid
Address of Property: I l q ,1,tV6 a a k [Zia IliturDOfZ$r-1�-----
Mailing Address of Owner %� <� C&rhf.
Owner's email: SIN n n tffli Ct 4t� §401 •toAOwner's Phone#: 7R ' Z i0-S
-- r -
Agent's Name:
Agent's Email:
Agent Phone#:
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom Rortion to be completed by the Adjacent Property Owner)
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.
-AZ1 DO NOT have objections to this proposal. I DO have objections to this proposal.
If you have objections to what is being proposed, you must notify the N.C. Di ion of Coastal
Management (DCM) in writing within 10 days of receipt of this notice. Correspondence should be
mailed to 400 Commerce Ave., Morehead City, NC 28557. DCM representatives can also be contacted
at [phone]. No response is considered the same as no objection if you have been notified by
Certified Mail.
WAIVER SECTION
understand that any proposed 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
(this does not apply to bulkheads or dprap revetments). (if you wish to waive the setback, you must sign
the appropriate blank below.)
t DO wish to waive some/all of the 15' setback
-7z--
Signaturw6f Adjacent Riparian Property Owner
-OR-
1 do not wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner.
Typed/Printed name of ARPO: i OZ~ d✓ I
Mailing Address of ARPO: Ac • rr.
ARPO's email: Z%� U flgk �GN 6PO's Phone#: 414 _q 1 Z' Q Z Z
Date: At I! i �1'�ZI 'waiver Is valid for up to one year from ARPO's Signature'
Revised July 2021

0

74
N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
CERTIFIED MAIL • RETURN RECEIPT REQUESTED or HAND DELIVERY
(Top portion to be completed by owner or their agent)
Name of Property Owner. --DQy i ill 4, ►)A.r10' ';Y-as
/w�l l
Address of Property: 219
L! a a a L R0NMailing Address of Owner. Z7ct jUC aalc od iU70,L
4tT
Owner's email: _gdtV VICAM MCA 5+0 A1.Cc y Owner's Phone* Z S 2 q 0 270,5
Agent's Name: Agent Phone#:
Agent's Email:
ADJACENT RIPARIAN PROPERTY OWNER,S CERTIFICATION
(Bottom portion to be completed by the Adjacent Property Owner)
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
I DO NOT have objections to this proposal. I DO have objections to this proposal.
If you have objections to what is being proposed, you must notify the N.C. Division of Coastal
Management (DCM) in writing within 10 days of receipt of this notice. Correspondence should be
mailed to 400 Commerce Ave., Morehead City, NC 28557. DCM representatives can also be contacted
at [phone]. No response is considered the same as no objection if you have been notified by
Certified Mail.
WAIVER SECTION
I understand that any proposed 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
(this does not apply to bulkheads or riprap revetments). (if you wish to waive the setback, you must sign
the appropriate blank below.)
I DO wish to waive some/all of the 15' setback
Signature of Adjacefit Riparian Property Owner
-OR-
I do not wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner.
Typed/Printed name of ARPrOy : M i iL G 9 e M A A t A
Mailing Address of ARPO: l_ 1 1 Live Oak. y,0 Ali N f'w�0_Or � j N( Z s p
ARPO,s email: OdCI'I'ia t'I a (� W M1 kt tiS�Pi00 s Phone#:
Date: it �' 2p2 I -waiver is valid for up to one year from ARPO,s Signature`
Revised July 2021

A

.,
�-
M
p `

�I.