General Permits (1858)

-Y
CERTIFICATION OF EXEMPTION (-0
FROM REQUIRING A CAMA PERMIT
as authorized by the State of North Carolina,
Department of Environment, Health, and Natural Resources and the Coastal Resources Commission
in an area of environmental concern pursuant to 15 NCAC Subchapter 7K .0203.
Applicant Name GO5 q - v Phone Number 7/ %-
Address
City R,, ! , , ., A State Zip
ProjectLocation(County, State Road, Water Body, etc.) 1.1,, , _2 -zin -1- ,/ 5 I 3 ' ,�.
Type and Dimensions of Project l 00 ' ­7 ,�c.,& -1 'On r a b4L,-.0 le At —
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.
development is exempted, will be in violation of the CAMA if there
is a subsequent determination that a permit was required for the
40
evelopment.
he 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.
This certification of exemption from requiring a CAMA permit is
valid for 90 days from the date of issuance. Following expiration,
a re-examination of the project and project site may be necessary
to continue this certification.
CAMA Official's signature
a-le-1y
Issuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

ADJACENT RIPARIAN PROPERTY OWNER STATEVENT
I hereby certify that I own property adjacent to
Is property located at
( Name of Property owner) 1 �l l
�U I 1�( (mot 0t zo I°� � �a{;ice I k
(Lot, lock, Road, Uje�,t�c. l
on►(.k Si lti;� in _e}%7,IWI��J`�I \ . N.C.
.rti'odf � (1.0,an a-n fo 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.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMr;N't:
(To be filled in by individual proposing development)
1� (Lllc�—
OA-�- Ux % � 6 b
6� Kb. iA* M Ii�
a "k ,,A 1L 0 6"i- A+
6" Null U0'J\oa& G,
UAA-L �N AJ lS �4&
r f �
signature` ,
Print or Type Name
Telephone Number

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby -certify that I own property adjacent to
Is property located at
(Name of Property Owner
(Lot, Block, Road, etc.)
11 JJ
on _� CIS ,k rP in /_,-���`ZCS �--
�`AA,-ij N.C.
(Waterbod�i) (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.
Y1 i 1
Vr�
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
1 {� , j , . j
111�-
Signature
\) . �� "'�) a
Print or Type Name
Telephone Number