Adjacent Riparian Property Owner Statement

(FOR A PIER/MOORING PILINGS/BOATLIFT/BOATHOUSE)


I hereby certify that I own property adjacent to ________________________________________'s
  Name of Property Owner
property located at _____________________________________________________________,
  Lot, block, road, etc.

on ____________________________________, in _______________________________, NC
Waterbody Town and/or county

He has described to me, as shown below, the development he is proposing at that location and I have
no objections to his proposal.

_____   I do not wish to waive the setback requirement.

_____   I do wish to waive the setback requirement.

___________________________________________________________________________

Description and/or Drawing of Proposed Development
(To be filled in by the individual proposing development)












___________________________________________________________________________


______________________________
Signature

______________________________
Print or type name

______________________________
Telephone number

______________________________
Date