General Permits (2277)

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;.Y CERTIFICATION OF EXEMPTION
FROM REQUIRING A CAMA PERMIT BP
as authorized by the State of North Carolina,
Department of Environment, Health, and Natural Resources and the Coastal Resources Commiss
in an area of environmental concern pursuant to 15 NCAC Subchapter 7K .0203.
Applicant Name e r
Address
City
Project Location (County, State Road, Water Body, etc.)
State
Phone Numberi-d 91A-
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.
,171- r
I/
Zip
/r
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.
SKETCH (SCALE: )I
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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 Applicant's signature
development is exempted, will be in violation of the CAMA if there / .I- , ) , '`..F It
is a subsequent determination that a permit was required for the
CAMA Official's signature
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.
Issuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

19/1995 13: 58
2661226
CLEMEHTS F H
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ADJACENT RIPARIAN PROPERTY OWNER
STATEMENT (FOR A PIER)
I hereby certify that I own property adjacent to
Travis & Linda Clements is property
located at Lot 9, Block "15", Sound Drive _ _, on
(Lot, Block, Road, etc.)
Canal in Atlantic Beach , N.C.
(!dater bodY) (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 understand that a pier must be set
back a minimum distance of fifteen feet (151) from my
area of riparian access unless waived by me.
N/A I do not wish to waive that setback requirement.
N/A I do wish to waive that setback requirement.
Si n ure4v�
•moo a R n
Name
Phone number

ADJACENT RIPARIAN PROPERTY OWNER
STATEMENT (FOR A PIER)
I hereby certify that I own property adjacent to
Travis & Linda Clements is property
located at Lot 9, Block "15", Sound -Drive , on
(Lot, Block, Road, etc.)
Canal in Atlantic Beach N.C.
(Water bodY) Y (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 understand that a pier must be set
back a minimum distance of fifteen feet (15') from my
area of riparian access unless waived by me.
N/A I do not wish to waive that setback requirement.
N/A I do wish to waive that setback requirement.
Signature
AWX
N me
Phone number