General Permits (4023)

7 L //wTi
r CERTIFICATION OF EXEMPTION
FROM REQUIRING A CAMA PERMIT
as authorized by the State of North Carolina, O
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 s - Phone Number '
Address
City _ State
Project Location (County, State Road, Water Body, etc.)
Type and Dimensions of Project
Zip
The proposed project to be located and constructed as described This certification of exemption from requiring a CAMA permit is
above is hereby certified as exempt from the CAMA permit re- valid for 90 days from the date of issuance. Following expiration,
quirement pursuant to 15 NCAC 7K .0203. This exemption to a re-examination of the project and project site may be necessary
CAMA permit requirements does not alleviate the necessity of to continue this certification.
your obtaining any other State, Federal, or Local authorization.
_4`1 (- -
SKETCH (SCALE: )
8
all
d
b.t
V
1
rS
1 �1L t
i
---------- 4-
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
(FOR A PIER/MOORING PILINGSIBOATLIFT/BOATHOUSE)
I hereby certify that I own property adjacent to
GerRI� W CU��.;v
(Name of Property Owner)
's
property located at , /y ©f 7%
(Lot, Block, Road, etc.)
on cqm 15t� , in ����wfG RfOc,4 , N.C.
(Waterbody) (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.
I do not wish to waive the setback requirement.
y I do wish to waive that setback requirement.
ION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filed in by individual proposing development)
jf
JUL 1 0 1997
Print or Type Name
Telephone Number
Date: 7 �9

JUL-09-97 WED 10:11 AM COOPER 213 876 8611
Jul. 8 197 16: 20 FAX
ADJACENT XWAMAN FROPMTY OWNR STATMENT
(FOR A PI "OORNG a PLUNG"OATLIPTIBOA2710USE)
I hey certify that I own property Aacent to � +a W • , �c s t VJ ' a
(Now of P"petrty Ownw)
propeaty located at f tVi� _
(LAAr Blocko Rom etc.)
on in C C/ e N.C.
(Watex ]y) (Tawn andfor County)
He tins dmribed W me, a3 shown below, the dwmbpmmt bo i.3 proposing at that
location, and, f have no ohjecdom to his pFraposal. I understand that a Oulmood%
p- ingAoatlift/boafhousc mist be 3cd back a minimum distance of � feet (IS') from my area
of riparian aces unless waived by sue.
i not wish to waive the setback rmiremGnt.
I wish w waive that setback requirement.
P_ 01
P. 2
--- -�- �- _------------------------
DESCRUMON AND/OR DRAWING GR PROPOSED DR �..... .,..;;..� �. ,
(To he f &d In by iadivtduaI pruposkg development) +
JUL 1 0 1997 j
IJ
t or Nam
TetephMe Nui nber
w"""42P.
i
Date: