General Permits (3319)

CERTIFICATION OF EXEMPTION C� Y InJ'
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 f�'�
Address
City r
Project Location (County, State Road, Water Body, etc.)
Phone Number f r'
State ,/L " Zip 4-, % 11
y; pp f C' (;
Type and Dimensions of Project J' f • /'� r .4 1 °,&-,
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.
SKETCH (SCALE: )
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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 1
x
CAMA Official's signature
Issuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

MAR-04-199e 09:21 FROM DCM MOREHEAD 919 247 3330 TO 7263903 P.02
(.rutC A PI&KIMUURING P&INGSIBOATZIFT/BOAT'HOUSE)
I hereby certify that I own property adjacent to 1�8N1V VTR f xpn E, A/ -R147L:75 ,s
(Name of }'roperty Owner)
property located at / y STIZ r9 1 TS o 19 D
bvH ►7`E t•} urt T (Lot, Block, Road, etc.)
on CKEEK , in 6:40VCE5TER CARTE/ZE'T
N.C.
(Waterbody) (Town and/or County)
MR, 73A 7 E S l 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/mooring
pilings/boatliftlboathouse must be set back a minimum distance of fifteen feet (151) from my area
of riparian access unless waived by me.
I do not wish to waive the setback requirement.
I dQ wish to waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVEWFYIENT:
(To be , j rlled in by individual proposing development)
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Signature
Print or Type Name
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Telephone Number
Date: lvq — f I — 98
TOTAL P.02

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