General Permits (3721)

-� GE:RT��CATION Q:F 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 Subehapter 7K-.0203.
Applicant Name -6�// -�
Address
City c Aso
Project Location (County,
Type and Dimensions of Project
Road, Water Body, etc.)
x- // 2
The proposed project to be located and constructed as described
above is hereby certified as exempt from the CAMA permit re-
quirement pursuant.4o-1-5-4GAC--71<, , 2-03. This exemption to
CAMA permit requirements does not alleviate the necessity of
your obtaining any other State, Federal, or Local authorization.
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Phone Number '/5- Z 3 7 -.3 7 2 3
State /CA- Zip
d; fix• c 'ru lo;a�p �..a /
This c�rli ication of exemption from requiring a CAMA permit is
valid for 90adays from the date of issuance. Following expiration,
a re-examination of the project and project site may be necessary
to continue this certification.
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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
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 haveno-objections-to-the-
pxoposed work.
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Applicant's signature
CAMA Official's signature
2 - /9- 9
Issuing date
f- 31 91
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

YOBOX 776 PAMLLCO CUUN1'Y BUILbING IN;iPEUTIONS BAYBORO, N.C.
Oi9) 745-3661
(After this form is completed by the landowner proposing the project,
a cgpy is given to his/her 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 Inspections'
Office for building permit application/processing.)
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT EPN#
I hereby certify that I own property adjacent to
—is on
Name o� landowner proposing development body of water
in/near Loth of
community Subdivision, if applicable
Tax Parcel 4 off I Complete description of how to
locate this property:
The proposed project, a f / LJ �� and the location has been
described to me as shown in the drawing below and I have no objections
to the proposal.
FOP. A PIER, CHECK ONE OF THE FOLLOWING:
I wish to waive the 15' minims setback from my riparian access.
I Do NOT wish to waive the 15, minimum setback requirement.
e::**t+r*r*** ss•t*�:♦**ttt*•r:***♦♦t••rw�•t***t+�ttett•e***•tttt*tttftts►i►
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.
gaa�i y

POBOX 776 PAMLICO COUNT' BUILDING INSPECTIONS BAYBORO, N.C. 2651:)
[phone]
(After this form is completed by the landowner proposing the project,
a cgpy is given to his/her 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 Inspections'
Office for building permit application/processing.)
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT EPN#
I hereby certify
e� C- 's
Name of/landowner pro osing development
�� `r/�
in/near £'il/tl � Lot
community
that I own property adjacent to
on � � F �'_�
body of water
of
Subdivision, if applicable
Tax Parcel 4 off SR Complete description of how to
locate this property:
The proposed project, a , and the location has been
described to me as shown in the drawing below and I have no objections
to the proposal.
FOP. A PIER, CHECI. ONE OF THE FOLLOWING:
.� I wish to waive the 15' minimum setback from ay riparian access.
I DO NOT wish to waive the 15' minimum setback requirement.
*****::*:*Ra ssw**twt•w+r,t**:r*RR*ra*tw*w*a*:t**t*et*�►*es**tt*t,►e:i*ss:*
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.
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