General Permits (3424)

'71—;
CERTIFICATION OF EXEMPTION
_Y FROM REQUIRING A CAMA PERMIT 9(0�
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 Phone Number
Address
City State Zip
Project Location (County, State Road, Water Body, etc.)
Type and Dimensions of Project
The proposed project to be located and constructed as described This certification of exemption from requiring a CAMA permit is
above is hereby certified as exempt from the CAMA permit re- valid for 90 days from the date of issuance. Following expiration,
quirement pursuant to 15 NCAC 7K .0203. This exemption to a re-examination of the project and project site may be necessary
CAMA permit requirements does not alleviate the necessity of to continue this certification.
your obtaining any other State, Federal, or Local authorization.
SKETCH (SCALE:
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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
is a subsequent determination that a permit was required for the I
development. CAMA Official's signature
The applicant certifies by signing this exemption that (1) the ap- Issuing date
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 Expiration date
proposed work.
Attachment: 15 North Carolina Administrative Code 7K .0203
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ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to
�o6/e� 0eo"rC�4C-� 's property Tic 6gecF �c
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located at 9 )C' <)-4'7&�< 13M KC ; - LoT on
(Lot, Block, Road, etc.)
ROC of So ONO in M&)/0d4-F 7-9. ?o , N.C.
(Water Body) (Town and/or County)
He has described to me as indicated below the development
he is proposing at that location and I have no objections
to his proposal. I understand that a pier, pilings and
dredging must be set back a minumum distance of fifteen feet
(15') from my area of riparian access unless waived by me.
I do not wish to waive that setback requirement.
I do wish to waive that setback requirement.
Description and/or drawing of proposed development:
(To be filled in by individual proposing development.)
INS74LL.d-T1oti1 OF 1/0 L.W6,4L FEET Or I<JTCeLdCeiNe)' Uil"gL
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Date�—T
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Signature
Print Name ' /1
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Phone Number