General Permits (3446)

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.
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
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: )
1 I
I
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's signature
CAMA Official's signature
Issuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

Adjacent Riparian Property Owner Statement_
SIGNATURE ` g
zwtc� ' DATE C� - / Y
I hereby certify that I own property adjacent to G AAJ"Ziwaevelopment
' �i Xz
Name of landowner
on /J6)S �r G i /' f in/near Lot# of
Community Subdivision, if applicable
Tax Parcel# off SR
Complete description of how to locate this property
This proposed project, a el �n and the location has been described to me as
shown in the drawing below and I have no objections to the proposal.
For a Pier, check the Following;
// I wish to waive the 15' minimum setback from my riparian access
I do not wish to waive the 15' minimum setback requirement.
Draw the proposed structure in the space provided below. List the size of the structure and
measured distances from the adjacent property lines, other structures on the property, and the
road, water, etc.
r
After this form is completed by the landpwner proposing the project, a copy is given to the adjacent
landowners for their consent and signatures. The forms are then returned along with a building plan
and other applicable required information to the Building Insp. Office for building permit application/
processing.

Adjacent Riparian Property Owner Statement
SIGNATURE DATE_ 6 —
I hereby certify that I own property adjacent to fX A,)16�- i�✓f ! C/_
Name of landowner proposing development
on /'l fsdlc" in/near Lot# of
Community
Tax Parcel# off SR
Complete description of how to locate this property
Subdivision, if applicable
This proposed project, a Plil? and the location has been described to me as
shown in the drawing below and I have no objections to the proposal.
For a Pier, check the Following:
i✓I wish to waive the 15' minimum setback from my riparian access
I do not wish to waive the 15' minimum setback requirement.
Draw the proposed structure in the space provided below. List the size of the structure and
measured distances from the adjacent property lines, other structures on the property, and the
road, water, etc.
�x
4M
After this form is completed by the landpwner proposing the project, a copy is given to the adjacent
landowners for their consent and signatures. The forms are then returned along with a building plan
and other applicable required information to the Building Insp. Office for building permit application/
processing.