General Permits (2377)

Applicant Name _
Address
City
Project Location
-i l�l"G
CERTIFICATION OF EXEMPTION A4
FROM REQUIRING A CAMA PERMIT
as authorized by the State of North Carolina,
Department of Environment, Health, and Natural Resources and the Coastal Resour ommission
in an area of environmental concern pursuant to 15 NCAC Subchapter 7K .0203.
Phone Number qi % 12,2
State Road, Water Body,
State
3/
Zip
Type and Dimensions of Project , a ! c ' R k 3 2
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.
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.
I 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
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 signature— T
CAMA Official's signature
Issuing date
Expiration date'
Attachment: 15 North Carolina Administrative Code 7K .0203

ADJACENT RIPARIAN PROPERTY OWNER STATEhiEN'I'
I hereby certify that I own property adjacent to
Property located at Ll�\
(lot, block, road, C.
on �N in
( y of water) ' L e,) _
North Carolina in Pamlico Count (town)
y. The proposal has been described to me as shown below;
the development, a pier/bulkhead/structureand the
proposed location, and I have no
(circle one)
objections to the proposal. I understand that if the development is a pier, it must
j he 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.
(circle one)
Description and/or drawing of proposed development: (to be filled in by individual
proposing development.) INDICATE THE SIZE AND LOCATION OF THE STRUCTURE AND THE
DISTANCE BETWEEN EACH PROPERTY LINE AND THE WATER.
1
(Or ginal must be retained in the Inspection Department)
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da e
1ee ase Printl .•�_,__ ___._...

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ADJACENT RIPARIAN PROPERTY OWNER STAT MqT
I hereby certify that I Own property adjacent to'
C
property located at
on
(lot, block, road, et
in
(body or water) (town)
--
Cdorth Carolina in Pamlico County. The proposal has been described to me as shown below;
the development, a head/structure, and the proposed location, and I have no
Jrcleone)
objections to the pI understand that if the development is a pier, it must
be set back a minimum distance of 15 feet from my area of riparian access unless waived
by me. I do o not wish to waive that setback requirement.
(circle one)
Description and/or drawing of proposed development: (to be filled in by individual
proposing development.) INDICATE THE SIZE AND LOCATION OF THE STRUCTURE AND THE
C:ISTAr'CE BETWEEN EACH PROPERTY LINE AND THE WATER.
3y
N
(Original must be retained in the Inspection Department)
14-
MA
Name (Please Print)

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