General Permits (3474)

CERTIFICATION OF EXEMPTION
FROM REQUIRING A CAMA PERMIT � 1,_2f ,_) ', �_
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 C D.f' `� S -
Address 1 <' i n% k-3 ; v_.�
City,,
Project Location (County, State Road, Water Body, etc.)
.O
Type and Dimensions of Project i ► 3 t r-
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.
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.
State
a
Phone Number 4 �� `i �i q t/3;
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.
CAMA Official's signature
Issuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

03/24/1998 07:19 919728382E NOE@HOLl.E PAGE 02
AUJACENr RWARMN PROPERTY OWNER STATEMENT
(FOR A PIEWMOORING PILINGSIBOATZIF1YgOATKOUSE�
I herebY certify that I own property adjacent to
(Name of Property Owner)
Property located at �D//d/J17�,// iL//�r�.� . /_
(Lot, 1310ck, Road, etc.)
aterbody)
in
l',� / �C'Q , N.C.
(Town and/or County)
lie 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 drat a pier/mooring
pilings/bvatlift/boathouse must be set back a adnimurj dista,ce of b een feet 15'
of riparc
ian access unless waived by ine. ) from my area
I donot wish to waive the setback requirement.
1110 wish to waive that setback requirement.
DESC1tIMON AND/OR DRAWING OF PROPOSED
(Tv be DEVRI'Op�T:
1 d in by individual prpposirtg development)
2 U--,vEGrJ
Print or Type Name
Telephone Number
Date:

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03/24/1998 07:19 9197283828 N00HOLLAND PAGE 02
"JACFM RZPARMN PROPERTY OWNER
{FOR A PIERIMOORING p1MNGS1B0ATLZFT roUs
I hereby certify that I own property adjacent to 1G� 7�
(Name of Property Owner)
(Lot, Flock, Road, etc,) '
on,���D N.C.
a� rbody) (Town and/or County)
He has described to me, as shown below, the development he is proposing at that
location, and, I have no objections to his nronosal. I unders+znd that a pier1jr0, -,-1S
,P'Ungs/boatlifVboathouse must be set back a rni� mum distznce Of feet ll j>) from my area
Of riPanan access unless waived by me.
- I S-0-nQJ wish to waive the setback requirement,
V _ I do wish to waive that setback requiremenL
DESCRIMON AND/OP. DRAWING OF PROPOSED DEVFjI OP712FNT:
(To he fllled in by individual Pmposing development)
l
Signature
., A w, es J . ( A 2 liz,
,Print or Type Name
s�(,� S At I ��2\
Telephone Number
Date: A, 5 - 1gq$

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