88639C - Clark, William & Edwin

�JCAMA [' DREDGE & FILL JYK� N9 88639 A B (fPD
''€ G Previous permit
E N E RAL PERMIT
Date previous permit issued
New ❑ Modification ❑ Complete Reissue ❑ Partial Reissue
As authorized by the State of Nooirth� �Cyaro�lina. Department of Environmental Quality and the
�r,yytCoastal Resources Commission in an area of environmental concern pursuant to:
15A NCAC %
G`R / /❑ Rules attached. l General Permit Rules available at the following link: v^vvydeq.nc.gov/CAlvlArules
Applicant
City 12
Phone #
VAIi
Authorized Agent I
Project Location (County):
Street Address/State Road
City
Affected ❑ CW _,NJEW _JZJ❑ PTS Adj. Wtr. Body 9 man/unk)
AEC(s): ❑OEA ❑IHA UW SPIMA ❑ PWS Closest Maj. Wtr. Bodv
ORW: yes/ho )` PNA: ye(JS>
Type of Project/ Activity
(Scale
Shoreline Length
Access Length
Pier(dock)length
Fined /A_
Platform(s) (s) I°�
x s
Floating Platform s)
Finger pier(s) \\
Total Platform area
Groin length/# N Q0✓
Bulkhead/ Riprap length �O
Avg distance offshore
Breakwater/Sill _ / Z �l(
Max distance/ length
Basin, channel
Cubic yards
Boat ramp
Boathous Boatli x
Beach B ly
rg
Other
SAVobserved: yes Moratorium:
y vlOtr f�, OL
Moratorium: n/a yes no ` 1
Site Photos: es n
Riparian Waiver Attached: o
A building permft/zoni'29 permil maybe req 'red by: O f
Permit Conditions ! n C2 C ., J ❑ TAWPAM/NEUSE/BUFFER (circle one)
P^ t a� ❑ See note on back regarding River Basin rules
SIKAt n
❑ See additional notes/conditions on back
or
Si ture`*-PPllease ad compliance statement on back of permit*"
A Iir�on Fees Check#/Money Order

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:
Tar - Pamlico River Basin Buffer Rules 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

CAM4 ®SEDGE & ALL 8863 A B Gc�D
�EP
Previous permit
PERMIT IT
Date previous permit issued
,®Non ❑Complete Reissue []Partial Reissue
As authoriz=_d by the State of North Carolina• Department of Environmental Qualityand the Coastal RsSoU(CCa Commission in an area of environmental concern pursuant co:
ISA NCAC l � ..F r � ss�- F Rules attached. � General Permit Rules available ar the following link: wwwdeoxc gcv/CAMArule
Applicant Name 1 . t o}, Yi k pit F � #"{+' } ( J�.`k y^ q Authorized Agent s3 he-
AddresP 1r � i +s�l; A t i >r er".,,'�Vf Project Location (Coumy}:
city A r S i ° � ''� State t .� Zip + +' _"'+3y Server ,`.., 'AddtasstState Road/Lot #(x)
4 7
Phone �`{ =,f) 'r'-ia_p-. new: "f -� F,r i'`i� �i.✓'t'ti ''�.,� �ijcr"lY r,
Email
SubdM516n
i { y
�`,��.� t; {{--�� City ZIP ,.-'s^"✓"�°
Affected �L`W „r�� ....t= .--=�" ,LJ PTs Adj. Wtr. Body z ..,! ^� P' Y7 i},r 1 h man!unk)
AEC(sj: ''s,FlOEA IFIA L-3UW 11SPIMA DPWs Closest Mai, Wtr. Body_ e,:a'-'+`r i',(E.- ..,.,.=° {.'T.^'-y'
ORW: yes6n', PCtA: yes/fi'a
Type of Project/ Activity i � t '` = a %' g p' � f 4—� ° y
' (Scale('/ 20
Shoreline Lengthk
t
Access Length
Pier (dock) length
FiV,Platfor (sj U70 �-••i- ,���, Vl"!i t4,.�lj VU/
Floating PlatformTs)
Finger piers)
Total Platform area
Groin length/q t\�l a�lp�
Buikhead/Riprap length h,,`/'
Avg distance offshore •6�'� .� Jam,_. e
&eakwatkwaterJSiil __"'_'_7�� ✓"�-•' -
Max distance/ length
Basin, channel
Cubic yards
Boat ramp
Boathous Boat)i zJ
Beach 8 z g `
other site nll
}� }
observed: yes 'Y �Nt
Moratorium: nfa yes no t_ L=-----
Site Pharos: as rt
Riparian Waiver Attached to �� t/��` .-%-
Abuilding permit/zoning per mit may be requ'red by. OCP,0,C,1 C-1 +Y
c',, TAR/PAMiNEUSEJBUFFER(circle ona)
Perm it Conditions
li?p'l�(i'T�C'P,� -i, e Lip i �I ixf 4;v� M see note on back regarding River Basin rules
See additional notes/conditions on back
or
an
4175
Order

Name of Property Owner Requesting Permit:,, EA I\, L ( LA,
Mailing Address: " 1a� Q L"-1., 1`1 Q calo_u ,Rci'j
Phone Number.
Email Address:
I certify that I have authorized
Agent i Contractor
to act on my behalf, for the purpose of applying for and obtaining all LAMA permits_)
necessary for the following proposer! development: � t.� �1a "r GfU C'/<
at my property located at J % � tAac t ' i� �Ct _J � � t C 5
in County.
i ,furthermore certify that 1 am authorized to grant, and do in fact grant permission to
Division of Coastal Management staff, the Locai 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 --
0,1)A,
Date
This certification is valid through _ t 3L i � �rZ--"

Name of Property Owner Requesting Permit: t L • dr'st:C..
Mailing Address:
Phone Number:
Email Address:
I certify that i have authorized
Wejdl2. N( )85cfc�
-�i(i -JJ ('7cl
to act on my behalf, for the purpose of applying for and obtaining all CAMA pfermit-s/
necessary for the following proposed develo ment. +-4 �� f do c �jam/
at my property located at L Cold 6 1�
in N- County.
t furthermore certify that 1 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.
Signature
il-'. C 4'-k
Print or Type Name
Title
t✓ � t � �3 t � t'�. �vs
Date
This certification is valid through _ i_ 3 t 'i�i

Name of Property Owner Requesting Permit: Mailing Address: -NoIS / (tar,Ae_
,:ale. , JOC
Phone Number: ; Icct1_"73oo
Email Address: _ , v �'[A� T� "" + e i`2. CaPA
I certify that I have authorized' �tiDl�S
Aoent i Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
` 9 3
necessary for the following proposed development: _� 1)ga'."d
at my property located at 1909 ���Son �� ��� I�4ac� (,
in �i" 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.
9E-7 •
Signature
Print or Type Name
Title
5 t
Efate
This certification is valid through _Ll t 31/ �'

Shared Dock Agreement
This Shared Dock Agreement dated�pr,�e( �3{� o2o�a is entered into
between Edwin L. Clark, the property owner at 1403 %Shackleford St., Morehead City, NC
28557 and William L. Clark, the adjacent property owner at 406 S. 1411' St., Morehead City, NC
28557. Edwin L. Clark intends to demo his existing dock and build a new one to be shared
between William L. Clark's property at 406 S. 14`1 St. The boat lift and slip on the east side of
the dock would be used for 406 S. 14"' St and the boat lift on the west side would be used for
1403 '12 Shackleford St.
Edwin L. Clark Date
cj/ 3 /R.?
William L. Clark Date

Name of Property Owner Requesting Permit: �A w L ( LA
MailingAddress: L3 - b-4L,
I certify that I have authorized
— LJNEZAB 1 11 � , 27c %
Agent I Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: —8L-41)6"0*'j 6k C/ <
at my property located at
in, cdiLrF�--7 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.
Property Owner Information:
Print or Type Name
Title
Date
This certification is valid through
2�55 7

�-- l i • � t"i_ err •.
s
Name of Property owner Requesting Permit: W, i 'etN 2 616'I .
Mailing Address:
Phone Number:
Email Address:
I certify that i have authorized
r
-79
Agent I Contractor
to act on my behalf, for the purpose of applying for and obtaining all LAMA permits
necessary for the following proposed develo ment: {J '4 '/0 CK
at my property located at
in C °' 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.
_I C�f/.- f 1/1
Signature
rr 4 3
Print or Type Name
Title
0t&' 1 t ,-; 1 �DC�R
Data
This certification is valid through

Shared Dock Agreement
This Shared Dock Agreement dated S��tri Uer 43{�{ aoa� is entered into
between Edwin L. Clark, the property owner at 1403 % Shackleford St., Morehead City, NC
28557 and William L. Clark, the adjacent property owner at 406 S. 14"' St., Morehead City, NC
28557. Edwin L. Clark intends to demo his existing dock and build a new one to be shared
between William L. Clark's property at 406 S. 14" St. The boat lift and slip on the east side of
the dock would be used for 406 S. 14"' St and the boat lift on the west side would be used for
1403'/ Shackleford St.
Edwin L. Clark Date
William L. Clark Date

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:
Mailing Address of Owner:
, .
Owners Phone#: ,"fdq-73od
Agent Phone# 49-6 .7— 1p,J 6 j,jZ
ADJACENT RIPARIAN PROPERTY OWNERS CERTIFICATION
(Bottom portion to be completed by the Adlacent Property Owne6
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
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 W.C. Division of Coastal
Management (OCMI 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 19 setback
-OR-
Signature of Adjacent Riparian Property Owner
I do not wish to waive the 15' setback requirement (initial the blank)
"-- Signature of Adjacent Riparian Property
Typed/Printed name of ARPO:
Mailing Address of ARPO: 111670 1.16001—S )T,
A7ARPO4P-asr9
ARPO's emaililur�e.ems©trllereka...%c:�'Phone#:
Date; le�--waiver is valid for up to one year from ARPO's Signature*
Revised July 2021

N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
CERTIFIED MAIL- RETURN RECEIPT REQUESTED or HAND DELIVERY
(Top portion to be completed by owner or their agent)
Name of Property Owner. _JD
;address of Property'
h4ailing Address of Owner'
Owne S email:
L4+4- W. et4rZK
0,4 P;t
[r
D10Ijr
u a7 e5+
;6X—102'7?40
AgerfsName �{>kL jfe car f�S AgentP'nonis1=. � _�67`56507/7-
{} Agent's Email; . c� 2%/( i1/ tilt' c { Cg"t11
Fi&)F->QS ='-D ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom portion to be completed by the Adiacem Property Owner)
i hereby certify that] own property adjacent to the above referenced property. The individual apa;/trg for tills
permit has described to me, as s^own on the attached drawing. the development they are proposing. A
r- 45, _ X ! DO NOT have objections tg :his proposal 1 DO have objections to this omoosal.
tf you have objections to what is being proposed, you must notify the N.C. Drvislon-of Coastal
AAanagement (DCPof} in writing within 40 days of receipt of this notice. Correspondence should be
marled to 400 Commerce Ave., Morehead Cify, NC 28557. DChi representatives can also be contacted
at (1 52} 808.2808, No response is considered tha same as no objection if you have been nofiired by
Certified Mail.
WAIVER SECTION
I understand that any proposed pier. desk, rnconno pilings. boat ramp. breakwater, boathouse. Irt, cr
groin must be set back a minimum distance of 15-from my area of nparian access unless waived by,
!this does not apply to bulkheads or riprap revetments). (If yo4 wis^ to waive the setback. you must sign
the appropriate blank below.)
i DO r;fish to waive some?all of the ' 5' setback
Signature of Adjacent R:aarian Property Owner
-OR-
F. I do not wish to waive the 15' setb&ck requirement (initial the
..-'r Signature of Adjacent Riparian Property
TypediPrinted name of ARP O: rriYy� 1r✓ filet '�tr4 _
Mailing Address of ARPO: Po
ARPO's
am!��Jail! a YA } Li fire,` �tyz ` 5sec �r ARPO's Phone#: 2-5-2-5-2 Z q 1 - 414 t't
Date: `! 1 1-7-- 'waiver is valid for up to one year from ARPO's Signature`
/ Revised July 2021

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit:
Mailing Address:
Phone Number:
Email Address:
I certify that I have authorized
D Mr'-Q«U Vej
gre0c)l
Agent 1 Coi
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
at my property located at
in C .--tip County.
!J
t 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.
Property Owner Information:
Signature _
Print or Type Name
CJ c,JR,Q%
Title
�J15,�aa
Date
This certification is valid through
ASS 7

N.C. DIVISION' OF COASTAL [MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER MOTIF
qFR�T-1FLQQit1A1t-:,BTTURN RE"Plo-r ICATICiijilli"AIVER FORfLq
I— —
{Top portion to be e0mPl4ted by owner or -,heir agent)
� I
Name Of Property Owner 1—�JWM I e
Address of Property. -
Mailing Address Of Owner
Owners emafl� eL. to (a tirkkr.,'( A `
Phone#, 11&Lks-1
Agent's Name, 450u�, tRTZ0 — --
Agent Phona�,- '7-05 ',:;1
Agent's Emsil,�— 5y
cZ2557
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION,
93Lqv t
-
Ipermit has ctascrit;ed to me, as shown cn ?hc attache. drawing, the devc:io me hereby Certify that I own property adjacent to the abQvO referenced Property. The individual aPplying for' his
Posing. 6
i DO NOT have objectons b this pnaRosai. t DO have objections to this praposat.
- - -- ------
Coastal
ould be
at (252) gp$_pgp�_ No resoanse is considered a came as no objection ff you have CO[Itacted
cc imall. been notifierl by
I-IVAIVER sEcTioN
O
I understand that any proposed pier, dock. meeting Pilings, beat ramp. breakwater. boathouse, lift, or
grain must be act back a minimum tier,
m distance of ;5'from my area Of nPmrjan aCCOSS unless waived by me
(this does net apply to bulkheads or noac revctmerhti (if you Wish to waive the setbac!(, you t;tnsL-5jp_n
the 81313FOPriate blank below
I DO Wish to wave some/stf of the 16Seiback
-OR- Si9R,'?e0re Of Adpacent Riparian Property Cwner
i do not wish towaive the 16t serbacjc r,(jtjicm,,i Must the blink)
Signature of Adjacant Riparian Property� i,,wnaj,
Typed/Printed name of ARPO: c
fulaffing Address of ARPO'.
ARPO's email.{
SA44--Wtit PO a Phone":
Date:'�•vraiverualid for up to one Year from ARPO's Signature -
Re Mad July 2021

N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONNVAIVER 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:
Mailing Address of Owner: __Tatt�c N al�' tLAu + t/e cy a (
Owner's email:eju%,k� tz"'k (-M Owner's Phone#: ,�2Sg2'St� -ti 1
Agent's Name;. P# �P rLi�L�G3
7.
Agent's Email —
Agent Phone#; &.1
a •
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 t<he attached drawing, the development they are proposing. A
description or drawino with dfinens ons mustt be provided with this letter.
100 NOT have objections to this proposal. I DO have objections to this proposal.
If --- sjwl
you have objections to what is being proposed you must notify the N.C. Division of -Caastai
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, deck, mo&ng pilings, boat ramp. breakwater, boathouse, lift, or
groin must be set back a minimum distance of 16from 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 somefall of the 15' setback v!t
9M
Signature of Adjacent Riparian Property Owner
I do not wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner: -
Typed/Printed name of ARPO;
_..
Date:
`waiver is valid for up to one year from ARPO's Signature"
Revised July 2021

Name of Property Owner Requesting Permit: � • d4' L
Mailing Address:
Phone Number:
Email Address:
I certify that 1 have authorized
tl�u 0 t2, fa Ll
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
at my property located at
in County.
t 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.
Property Owner Information:
r ( jj Signature
1, ck-1 t-)t
Print or Type Name
Title
3oc��
Crate
This certification is valid through t�1

N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
_CER'CIEIED_MAIL RETURN RECEIPT REQUESTED,or-HAND-DELIVE-KY
(Top Wportion to be completed by
owner or their agent)
Name of Property Owner. 'tv� L. C u "_
Owner's Phone#: Z2 - 91 V -71 15
Agent Phoneme 26.2— 6,-9 & "S,7—/Z—
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom portion to be completed by the Adiacent 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
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 sion
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.
Typed/Printed name of ARPO: r (,�.0g j
Mailing Address of ARrr/dad PO:
ARPO's email Ti�rsr�i1�+ i` ARPO's Phone#:
Date: �5�2`� —�� .waiver Is valid for up to one year from ARPO's Signature*
Revised July 2021

N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATiONNVAIVER FORM
_CEBIIEtED-MAIL-• RETURN RECEIPT REQUESTED-or-HAND-DELIVER-Y
(Top portion to be completed by owner or their agent)
Name of Property Owner: W A I` a A L.
Address of Property:
Mailing Address of Owner:
r
Owners email: oii2.CoMOwner'sPhone#:�'�(t{-7�(
Agent's Namer Agent Phoneme
Agent's Email:_ Sdrf lf.Lemcgo' e ::4— 12 mm
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom portion to be completed by the Adtacent 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
_r I DO NOT have objections to this proposal. 100 have objections to this proposal.
It 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 to400 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.) �^J
100 wish to waive some/all, of the 15' setback Cites C /
-OR-
Signature of Adjacent Riparian Pro erty Owner
I do not wish to waive the 15' setback requirement (Initial the blank)
' Signature of Adjacent Riparian Property Own
TypedlPrinted name of ARPO:
Mailing Address of ARPO:
ARPO's email: ARPO's Phone#:
Date: waiver is valid for up to one year from ARPO's Signature*
Revised July 2021

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