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CERTIFICATION OF EXEMPTION
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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 Subchapter 7K .0203.
Applicant Name lrltfI✓Z Phone Number ;';_ OV73
Address ki, 61 6
City 7:,X. State zip ? `
Project Location (County, State -Road, Water Body, etc.)
Type and Dimensions of Project C— 1�4 q A S
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.
I SKETCH (SCALE: ' .,; ) I
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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 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
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POBOX 776 PAMLICO COUNTY BUILDING INSPECTIONS BAYBORO. N.C. 2B515
(919) 745-3861
(After this form is completed by the landowner proposing the project,
a copy 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#
t hereby certify that I own property adjacent. to
CW14C- CN"—LAN ,s on Ai:%c,,C;;j C L t—: F IC
Name of landowner proposing development body of water
in/near-)AwSc>-J CPEt►c H ILL-5 Lot# 16 of 5L-?j C'2c E-k Hs
community Subdivision, if applicable
Tax Parcel # ,q )}% off SR J v Complete description of how to
locate this property: Lcfi Orr= S� iae�• �.� `r�f}u3,c�� CrEEic' G>p V
The proposed project, a �7 and the location has been
described to me as shown in the drawing below and I have no objections
to the proposal.
FOR A PIER, CHECK ONE OF THE FOLLOWING:
1 wish to waive the 15' minimum setback from my riparian access.
X 1 DO NOT wish to waive the 15, minimum setback requirement.
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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Printed Name 6i9204-i) �, /�,g� t�wi,� Date_jyLZ�7 Signature
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PUBOX 776 PAMLICU COUNTY BUILDING INSPECTIONS BAYBORU, N.G. 2BSl.`)
(919) 745-3361
(After this form is completed by the landowner proposing the project,
a copy 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 PROPER'rY OWNER STATEMENT EPN#
t hereby certify that I own property adjacent to
car Pr C +4 py2 tk-N'3_,_) —Is on
Name of landowner proposing development
body of water
in/near _NSpa+ C2tEtc H t LL-5 Lotii 26 Of DA"05L Hi <<-5
community Subdivision, if applicable
Tax Parcel �� 1 �f $ off SR Jv Complete description of how to
locate this property: ccti 5P, !34- �.� +�A �c,� C�tE1c '�),Pjv
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.
FOR A PIER, CHECK ONE OF THE FOLLOWING:
1 wish to waive the 15' minimum setback from my riparian access.
I DO NOT wish to waive the 15, minimum setback requirement.
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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st~ °�a'� 5 ��'
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Printed Nan)'�MC,5 (i. (t?YA&J A tit ct! Date ' a —% Signature i" ��,o f 6G)"
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