General Permits (2223)

CERTIFICATION OF EXEM
FROM REQUIRING A CAMA PERMIT
as authorized by the State of North Carolina, U
Department of Environment, Health, and Natural Resources and the Coastal Re
in an area of environmental concern pursuant to 15 NCAC Subchapter 7K.0203`"'"...— -------- ,_..-a,....,,,,�y
Applicant Name
Address
City
Project Location (County, State Road,
Type and Dimensions of Project
Water Body, etc.)
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.
Phone Number 'D
State (---
I r
zip ( c
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.
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Any person who proceeds with a development without the con-
sent of a CAMA official under the mistaken assumption that the
development is exempted, will be in violation of the CAMA if there
is a subsequent determination that a permit was required for the
development.
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.
Applicant's signature
CAMA Official's signature
� 7
Issuing date
Expiration date
s cs
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Attachment: 15 Nt:)rth Carolina Administrative Code 7K .0203

DIVISION OF COASTAL MANAGEMEIJT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION1 W&IVER FORM
Name Of Individual Applying For Permit: Flo%Niv IgRQ)e-7'7L
Address Of Property: _L. o �" ( (Q 7" k''e e p U co
7 �e Y V t e_C Cvv�-7 QdC iru4 g,,oiiGC,. C .
(Lot or Street #, Street or Road, City & County)
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,
should be provided with this letter._
I have no objections to this proposal.
it you have objections to what is being Pronosed, please write the
Division cf Coastal Management 127 Cardinal Drive _Extension,
Wilmington, North Carolina 28405 or call 910 395-3900 within 10
days of receipt of this notice No response is considered the same
as no ob-iection if you have been notified by Certified Mail
WAIF?ER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boat
house, lift or sandbags 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 151setback requirement.
I do not wish to waive the 15'setback requirement.
Print Nam
Telephone Number With Area Code
g
y
IDFEE HN R

f 'J
GEC ?�' � _ .�•;IF;,T
ADJACF.N'Y' _RYPAR? N_�RUPERTY 10wN" Lq1:-71CATIt}i�1WAIVER FORLi
Name Of
Individual Applying
For
Permit:
Adtress
Of Property; Lo
��, r,�ileiceV
�Du r 2a�`�v�• ��9 �, OV G iU. ��u�v�oY
{Lot or Str et ,, Street or Road, City & Countl•!
i
hereby certify that I own property adjacent to the att.e-
referenced property. Tne individual apply::1 fcr this pe.-it r,_
described to me as shown on the attached dia::ing the develop, --en;:
they are proacsing. A description or drawing, with d ie^sic;,s,
should be prc-jided with this letter.
T have no objections to this Frcocsal•
It vc have objections to what is be,
inQ zGE y+i*� r �.
-�� �-
pivision of Ccastai ManaaerrP,Lt, 127 Cardir,z? ��•e �x.,���;4�
Wilmington., 14arr_h Carnlina 28405 or call 910 395-?9-3C
d1ays of rece nt CC th_s notice 1•Ir '"eSt�Cns� s i r _ n _ -
_s no ob ?c_ on if ya" b aye been notified by Cer i f e,2 M+i ; l
Y21urR SPCTION
I understand that a pier, dock, mooring p_ Ings, b=eat:„,: _er, bc; t
house, lift or sandbags must be set back a
from my area of riparian access unless waived L-y r•.e. r'If vGu
to waive the setback, you !- st initial tine aper:�,::aye bia„
below.)
V/) — I do wish to waive the 15'sattac}. requiram�;nt.
I do ncit wish to waive the 15'satback requirarent,
Signat Date
Print NatneQ� _ 2g 3 _ �9 $D
UAW
Telephone Number 7ith Area Code