Signature Signature*

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Signature. Signature*. Print or Type Name. Print or Type ... Number / email address. Date. Date*. (Revised Aug. 2014). *Valid for one calendar year after signature*

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT I hereby certify that I own property adjacent to ______________________________________’s (Name of Property Owner) property located at _____________________________________________________________ (Address, Lot, Block, Road, etc.) on ________________________________, in __________________________________, N.C. (Waterbody) (City/Town 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 fill in description below or attach a site drawing)

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 Owner Information)

(Adjacent Property Owner Information)

_______________________________

_______________________________

Signature

Signature*

_______________________________

_______________________________

Print or Type Name

Print or Type Name

_______________________________

_______________________________

Mailing Address __________________________________ City/State/Zip __________________________________ Telephone Number / email address

Mailing Address __________________________________ City/State/Zip __________________________________ Telephone Number / email address

_______________________________

_______________________________

Date

Date*  (Revised Aug. 2014) *Valid for one calendar year after signature*

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Ifyes, please list ait states or jurisdictions where you have had such a registration or license below. Use additional paper if necessary. RECEIVh 3. OCl 27 ZOfj.