General Permits (1729)

CERTIFICATION OF EXEMPTIO
FROM REQUIRING A CAMA PERMIT KUG 2 3 1993
as authorized by the State of North Carolina,lm_�L_t:ILTU (.,�L)
Department of Natural Resources and Community Development and thi jQuwara QQmmiA..9iQn
in an area of environmental concern pursuant to 15 NCAC Subchapter 7K .0203.
Applicant Name
Address
City
Project Location (County, State Road, Water Body, etc.)
Type and Dimensions of Project
The proposed project to be located and constructed as described
above is hereby certified as exempt from the CAMA permit re-
quirement pursuant to 15 NCAC 7K .0203. This exemption to
CAMA permit requirements does not alleviate the necessity of
your obtaining any other State, Federal, or Local authorization.
State
Phone Number',I j 3
Zip c,
This certification of exemption from requiring a CAMA permit is
valid for 60 days from the date of issuance. Following expiration,
a re-examination of the project and project site may be necessary
to continue this certification.
Any person who proceeds with a development without the con-
sent of a CAMA official under the mistaken assumption that the Applicant's signature
development is exempted, will be in violation of the CAMA if there 1n'�
is a subsequent determination that a permit was required for the
development. CAMA Official's signature
The applicant certifies by signing this exemption that (1) the ap-
plicant has read and will abide by the conditions of this exemp-
tion, and (2) a written statement has been obtained from adjacent
landowners certifying that they have no objections to the
proposed work.
Issuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

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a�
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own Property adjacent to Co's .s
*6%)Siox 4095 R
property located at L{� ,Sl �t�,f'r on CAN C
blot, oc , road, etc.) wa er
in -F C.Trd 0NSL0LJ N.C. He has
body) own an r county)
described to me as shown below the development he is proposing at that
location and I have no objections to his proposal. I understand that a pier
must be set back a minimum distance of 15 feet from my area of riparian
access unless waived by me. I do do not wish to waive that setback requirement.
circ e on
Description and/or drawing of proposed development: (to be filled in by
individual proposing development)
I 'I'�
2•�
signature
ame
aye e _.- L Cl 9 G
prone numoer

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property'adjacent to Snr.��_ ,s
property located at SE,6-J' on C,4A/,4 L
{lot, blqck, road, etc.) (water
in SURF C,7"i QA15L6 LJ , N.C. He has
body) own an To`r coup y
described to me as shown below the development he is proposing at that
location and I have no objections to his proposal. I understand that a pier
must be set back a minimum distance of 15 feet from my area of riparian
access unless waived by me. QId odonot wish to waive that setback requirement.
irc e one)
Description and/or drawing of proposed development:
individual proposing development)
o S-
signature
i/ name
phone number
(to be filled in by
Lz (Tl, Qh e ssu re T� e *Te 1