General Permits (4015)

-�r- CERTIFICATION OF EXEMPTION ro ^
FROM REQUIRING A CAMA PERMIT M'l{
as authorized by the State of North Carolina,
Department of Environment, Health, and Natural Resources and the Coastal Resources Commission 7
in an area of environmental concern pursuant to 15 NCAC Subchapter 7K .0203.
Applicant Name
Address
City
Project Location (County, State Road, Water Body, etc.) /,
State
Phone Number _(7 2 — �(, 12
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.
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This cc .aification 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.
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Am, norcnn uthn nrnnoorlc with n riovainnmcnt withmit tho nnn-
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
t (FOR A PIERIMOORING PILINGSIBOATLIFT/BOATHOUSE)
I hereby certify that I own property adjacent to &) , t - , ca—t�—'s
(Name of Property Owner)
property located at
(Lot, Block, Road, etc.)
on in , N. C.
aterbody) (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 proposal. I understand that a pier/mooring
pilings/boatlift/boathouse must be set back a minimum distance of fifteen feet (15') from my area
of riparian access unless waived by me. r
I do not wish to waive the setback requirement.�� SCP 0 8 1y51
I do wish to waive that setback requirement. ,JJ�
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
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Signature
— CA #- 11 --1- o
Print or Type Name
/9- ,,I- " - 1�
Telephone Number
Date: ! a 99