General Permits (4201)

-Y
CERTIFICATION OF EXEMPTION Or Y
FROM REQUIRING A LAMA 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 e% �' �''._ i,f � ayk ->'. ✓ Phone Number '%'r'S-(911,
Address ! c�--I
City State ALlC. zip , G
Project Location (County, State Road, Water Body, etc.) &"."
Type and Dimensions of Project -z s, y
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: a; )
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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.
CAMA Official's signature
Issuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

I hereby certify that I own property adjacent to MAN/- +M61d 0�0 LbTa
property located at Lot l ( CkE !,-_ P-r. •`
(lot, block, road, etc),,
on Goy CjLEEK in _eye 1m Co
(body of water) (town)
North Carolina in p County. The proposa_. has been described to
me as shown beloir; the development, Dier b khc:ad;/structure, and the
(circ.'.e one)
proposed location, and I have not objection to th-e proposal. I under-
stand that if thy.: development is a pier, it must be set back a minimum
distance of 15 feet from my area of riparian accr:ss unless waived by me.
I doZo o wish to waive that setback requirement.
(circ a one)
Description and/or drawing of proposed development: (to be filled in by
individual proposing development). INDICATE THE SIZE AND LOCATION OF THE
STRUCTURE AND THE DISTANCE BETWEEN EACH PROPERTY LINE AND THE WATER.
3r�t /�7 rACH E�
Sec- •, ei,3 TAT
(original mLiZt be retained in the Inspectioz.t Departmept)
Date
Name (Please Print

x nerevy certify that I own property adjacent to �Wlk + LB-h y A W- L-b- CK
property located at LU 1 1 WEE ! - Pr, _
(lot, block, road, etc),.
on �od $ CjZ£�� in - l)", a l s FJ pro
(body of water) (town)
North Carolina in lWftLLCL_ county. The proposa:. has been described to
me as shown belov; the development, 'e b khe:a� u /strcture, and the
(circ:.e one)
proposed location, and I have not objection to the proposal. I under-
stand that if the development is a pier, it must be set back a minimum
distance of 15 feet from my area of riparian accf:ss unless waived by me.
I do do not wish to waive that setback requiremejit.
(circle one)
Description and/or drawing of proposed development: (to be filled in by
individual propo.,ing development). INDICATE THE SIZE AND LOCATION OF THE
STRUCTURE AND THE DISTANCE BETWEEN EACH PROPERTY LINE AND THE WATER. -
/�Tr�c�-f�1�
Sec o; TTf_
(original mt;st be retained in the Inspectioi.: Department)
gnatui/-eC-
Date
ew
Z e�� (PIE:ase Print
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