Adjacent Riparian Property Owner Notification Form printable pdf download

CERTIFIED MAIL · RETURN RECEIPT REQUESTED

DIVISION OF COASTAL MANAGEMENT

ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM

__________________________________________________

Name of Property Owner:

Address of Property:

(Lot or Street #, Street or Road, City & County)

Agent’s Name #: ________________________

Mailing Address: _______________________

Agent’s phone #: ________________________

____________________________________

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 description or drawing, with dimensions, must be provided with this letter.

______ I have no objections to this proposal. ______ I have objections to this proposal.

If you have objections to what is being proposed, you must notify the Division of Coastal Management

(DCM) in writing within 10 days of receipt of this notice. Contact information for DCM offices is

available at

or by calling 1-888-4RCOAST.

No response is considered the same as no objection if you have been notified by Certified Mail.

WAIVER SECTION

I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, or lift 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)

(Riparian Property Owner Information)

_______________________________

Signature

_______________________________

Print or Type Name

_______________________________

Mailing Address

__________________________________

___________________________________

City/State/Zip

__________________________________

___________________________________

Telephone Number / Email Address

________________________________

Date

(Revised Aug. 2014)

Adjacent Riparian Property Owner Notification Form