General Permits (3650)

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Applicant
Address -
City
Proiect Lc
CERTIFICATION OF EXEMPTION
R 10 1997
FROM REQUIRING A CAMA PERMIT ,„ t
as authorized by the State of North Carolina,
Department of Environment, Health, and Natural Resources and the Coastal Resources"Z ommission "'."'" ----
in an area of environmental concern pursuant to 15 NCAC Subchapter 7K .0203.
I C LL Ave r j /a _Tory, 1. (,1.5. Phone Number Sa3 � 3 � "? (+a 4. c ,
(County, State Road Wate9r Body, etc.)
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Type and Dimensions of Project „L..4W_ n L n 9 U Li.J4!- ;.3. sPgY\_Q_ AJ t c..ra
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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t
H o— . s—e
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' signature
CAMA Officials signature
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Issuing date
%o 1�G­7
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

EROSION CONTROL SPECIALISTS 66-30/31
133 2629
ATLANTIC BEACH CAUSEWAY NCDL 8039839
P O BOX 3355 PH 919-726-2191
ATLANTIC BEACH, NC 28512 9
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PAY TO TI IE
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I '� T CITIZENS
13A/� ArFiral-Citizens Bank 8 Trust Company
- Atl.nllc Beacn. N.C. 28512
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FOR .-In
1:0531003001: 13 1 211,85351"0 2r 29

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
206-•Z�2
I hereby certify that I own property adjacent to
op 47L.�4�T/c `9E-4?1 - C�o K« C'oX ' s property
located at giae -P,64 b Aoc AV- 90x (D - on
(Lot, Block, Road, etc.)
gO200E Quide-) in H lLA 4-rtc ge--4c 4 , 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.)
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Date
Phone Number
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