General Permits (2422)

Applicant Name
Address '
City k' <• /r'
Project Location (C
19
CERTIFICATION OF EXEMPTION
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.
Phone Number c uJ
,unty, State Road, Water Body, etc.)
ns of Project i 7
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.
Zip
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: )
'CI
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.
Ohe 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 signatu
CAMA Official's signature j
Issuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

FROM BLUE HERON WTSON BUILDERS PHONE NO. : 919 354 3737 P03
AbJACFI?T RIPARY,AN PROpEi2�'K OWNER. STATEMENT
IFOR A PIER)
l hereby ,certify that-T own PraPerty adjacent tD
Name. ° s property
located {3t
on
�-q (Lot,. Block,
(�Road, etc.) ,Y8
+Cf Ya a r e body)
h dy in • � �Cl ��and
4�.,'C �
(water body) {Town r ;oumty)
He has described to one as shown below the development he -is
proposing at that 10c$tion and ,1 have no objections to his
proposal. l understand that a pier must be set back a minimum
diStanCe of fifteen feet (151) from my area of riparian accexs
unless waived by me.
y I do not wish to waive that setback requirement.
I do wish to waive that setback requirement.
Description and/ter drawing of proposed development: (T� BE
IFILT. IN BY INDMDUAL PRoposING I)EVELC)pM �;TT}
Name
'i'2Z c%7V
Phone Number

'FROM .BLUE HERON WATSON BUILDERS PHONE NO. - 919 354 3737 PN2
ADJACENT RIPARTAN PkopERTy MNER STATM ENT
(FOR ,A PIER)
Ihereby certify that •i own .property adjaeept -to
C.A.
s�.c�. �^� csr rr. property'
Name
located at J?_
(Lot, Block, Road, �eta.l
Water Body)�. iri ..ice ` �+r• , N.C.
(Town and% r County
He has described to me as shown below the development he i5
.proposing at that 3ocatiojD &nd I have no objections to his
}7rvposal. I understand) that $ pier must be set back a minimum
distance of fifteen feet (151) from my area of riparian. access
unless waived by tne.
y e% I do not wash to waive that setback requirement.
,_ I do wish to waive that setback reguirement.
Description and/or drawing of prOposed development: (To BE
I'ILLHD )IN By INDIWDUAL PROPOSING DEVELAPMF.W)
Signature
Name
c?1I — ? 2 � --45-117
�'hone Number

FROM FLUE HERON WATSON BUILDERS PHONE NO. : 919 354 3737
FAxt 919-364-3737
A
Date
To t FAX
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Company-*
Number alb pages lnc]�uding th, a* cover Please call ,back right
away if you Flo not .receive all pages.
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