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NCDENR
North Carolina Department of Environment and Natural Resources
MichaerF Easrey, Governor ''''t'.tJ.:t :31Xt:lf3il3fl:It" wi,iam c, Ross Jr., secretary
,*"bh*ZL
Applicant Name
Mailing Add ress
(
5d \
6 Q
cacl neJc '*tk to act on my
behalf, for the purpose of applying for and o all CAMA Permits necessary to
Jeorwinstall or construct (activity)
at (location)L L1 Chr
This certifica ls thru ate)tSignature
?*rIl
RECEIVED
JuL l2 2022
DCM.MHD
CITY
400 Commerce Avenue, Morehead City, North Carolina 29557
Phone: [phone] \ FAX: [phone]\lnternet: www.nccoastalmanagement,net
An Eq!aJ opportunity \ Affirmative Action Employer _ 50% Recycted \ 10% post Consumer paper
I certify that I have authorized (agent)
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N
N.C. DIVISION OF COASTAL II/IANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
CERTIFIED MAIL ' RETURN RECE IPT REOUESTED or HAND DELIVERY
(Top portion to be completed by owner or their agent)
anName of Property Owner:
Address of Property:
Mailing Address of Owne ,.. P,I
f n\l c-
e VBe Z
Owner's Phone#
Agent Phone#.--
Owner's email
Agent's Name
Agent's Email:
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom portion to be comDleted bv the Adiacent ProDertv Owner)
I hereby certify that I own property adj acent to the above referenced property. The individual applying for this
perm it has described to me, as shown on the attached drawing, the development they are Proposing A
descri otion or drawi nq, with d im en sto ns,must be Drov ided with this letter
KCa,ooNor have objections to this proposar. _ l Do have ob.iections to thrs proposar
lf you have obiecti ons to what is being Proqose d, you must notifY tt:re N.C. Division of Coastal
Management (DCM)in writing within 10 days of receipt of this notice'Correspondence should be
mailed to 400 Comm erce Ave., Morehead CitY, NC 28557 . DCM represen tatives can also be contacted
at [phone]. /Vo response ,s considered the same as no objection if you have been notified bY
Ceftified Mail.
WAIVER SECTION
lunderstandthatanyproposedpier,dock,mooringpilings,b-o?trqmp'breakwater'boathouse'lift'orgroin
must be set back a minimum oi.t"'nt" oi i s; from
-my ar6a of riparian access unless waived by me (this
;;;j ;;t6plti. 51 lkheads or riprap revetments). (tf you wish to waive the setback, vou @glsig! the
appropriate blank below.)
I DO wish to waive some/all of the 15' setback
RECETVED
Signature of Adiacent Ripaian ProPeftY Owner
-oR-JUL 22 Z1ZZ
DCM-MHD CITY
Z? Signature of Adjacent Riparian P
Typed/Printed name of ARPo:
Mailing Address of ARPO:
roperty Owner:
at a5a .G '?o -
ARPO's email:
-Zket is ualid for up to one year from ARPo's Signature.
Revised MaY 2021
Datr:6-3D
rg3
I do not wish to waive the 15' setback requirement (initial the bllB)K
-.
),r ARPO's Phone#:
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