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AGENT AU RIZATION FOR-CAMA PERMITAPPLICATIGN
operty Owner Requesting Permit: de
i certify. That f have. authorized
. Agent 1 Contractor
Jo act on my behalf, for the purpose of: applying for and obtaining all CAMA*perm its _.
necessary for the following*.proposed, development: An� Y�v,4�
6 �
4
at my property located at
. in (.ih�f�'T County. .
i furthermore. certify that. l am authorized- to grant, and do in fact grant `permission to
Division of Coastal Mana.goem* ent staff, the Local Permit Officer and. their agents to enter
on. the .aforementioned lands in connection with evaluating information related to this
permit application. � s
Property Owner information:
17
2,0
Signature' j � �
2, 2/ z 3� Z y 2 (ol 2 7/ Z
Print or Type Name mom 271' 3 01 311 3 Z-
Tine 3 � � .37` 3 9 '1 /` q 2-1
Date
RECEIVED
This certification is valid through / �
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
49- -761 4AeX7-- s
certify that I own property adjacent to
V _ = (Name of Property Owner)
��� �/�
located at
(Address,. Lot, Block, Road,. etc.)
artfil Caw , N.C.
=� , in
(Waterfbody) (City/Tow and%or County)
The * applicant has described to me as shown below the development proposed at the above e
iocatio
I have no -objection to this proposal.
_... -----=---- --- -- I h av_e_o b j � c��o n��to_t �t'ts�. p rQp o s_aL___- __._-_-:-.-..-------.------ .___ �._
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(individual proposing development must fill in description below or attach a site drawing)
l��w--�' �-,�r� s .>v� �c � s�-�� 5 do, c.k S o� �-�o�t5� cLL /u�lNH�
�.D�t'Uk PPALA A-0-EN
WAIVER SECTION
I understand that a pier, dock, mooring pilings, 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.)
l do wish to waive the 15'setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
Print otType Name
P.o.i�vx' .3j Z,
Mailing Addres =! 40"RaA��
CitylStatelZ--
1p
Telephgnq Number
FrOM
(Adjacent Property Owner Information)
Signature
t TVZ
Print or Type N17n
Y P 0 .r SC/
Mailing Address
--- /v,<_
City/state/Zip
7
Telephone Numb r R$:C . D
Date
(Revised 6/18� � `�j�
CTY
c7 I
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
b
's
certify that I own property adjacent tod
- (Name of Property owner)
rt located aty2�" -
_p Y
(Address, Lot, Block, Road,: 2ec.)
inmo/�MiO�C, N.C.
(Waterbo'dy) - (City/Tow and/or County)
ff The a licant has described to me, as shown below, the development proposed at the above
pp
Io.cation
rn I have no objection to this proposal.
es
_. I ha j e cf n_s t_o�th Ls_: pr_o p o aL_^ _.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
,�in�T�t'T,� wj �if�-✓f �oc,�s 17�g�..b���'
Lb le, e_0
- WAIVER SECTION
I understand that a pier, dock, mooring pilings, 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 roust initial the appropriate blank below.)
I do wish to waive the 15' setback requirement.
do not wish to waive -the 15' setback requirement.
(Property Owner Information)
Si40� A��
ature
409#U:e 4z Z"4_1_,__
Pr►nt or Type Name
Po. e� 39 Z
Mailing A Tess
City/State2ip
Telephone Nuliber
� zlsr�
Date
(Adjacent Property Owner Information)
I>C JAAV�Vk. 5
Signature
Print or Type Name
-7 4&kE 6�c
�r�g, dress Ci7"y/VG c�dv��
City/Sta%/Zi
25Z—l2G - ?6 S5
Telephonq N tuber
Date
l a
(Revised 611812012)
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