General Permits (4227)

-Y CERTIFICATION OF EXEMPTION A ,
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 C`� Phone Number
Address
City State r Zip
P oject Location (County, State Road,, Water Body, etc.) T:n _e :--
Type and Dimensions of Project-Ti ' " ' . L4, /' L /' i J1' t '' , , !a
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 g0 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: )
6
Any persoh who proceeds with a development without the con-
sent of a LAMA 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.
111 `
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cf -
Issuing date
,; 17
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

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• ADJACE.N"T RWARUN PROPERTY OWNM STATEIVIEIgT
(FOR A PIERIMOORING Pi UNGSIBOATUT'TIMATHOUSE)
I hereby certify that I own property adjacent to l 4f- aA—
lS .S
(1Naume of Property Owner)
!f ll-d Sc
property located at
(Lot, Block, Road, etc.)
on t 15pd CAex-h , in Ct'AU'e�V Co Ale-afs'e-r l 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 (151) from my area,
of riparian access unless waived by me.
L'� I do iM wish to waive the setback requirement,
149 wish to waive that setback requirement.
DESCRIp'I'ION AND/OR DRAWING OF PROPOSED DEVELOMMNI':
(To be filled In by individual proposing development)
Se i?, a 40-ClA t-A NAIW r �
s
Telephone Number
Date: " •'�

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