General Permits (4308)

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Applicant Name
Address
City
Project Location
CERTIFICATION OF EXEMPTION,
FROM REQUIRING A CAMA PERMIT
as authorized by the State of North Carolina,v
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.
:ounty, State Road, Water Body, etc.)
Phone Number 2 Y9- 3901
T State A.IC- Zip .2ss' 7i
G . 0 /i - f2 /3 17. . •9
Type and Dimensions of Project ow, 6 'r 86 w w- ez' 6 r'A
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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 ification offs emption from requiring a CAMA permit is
valid for 90 days frQ he date of issuance. Following expiration,
nation of the project and project site may be necessary are �€a p l p) y
to continue this certification.
SKETCH (SCALE:
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�onr�SE�
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.
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pplicant's eigrfatuvo
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CAMA Official's si ture
Issuing date '
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

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PAMLICO COUNTY BUILDING INSPECTIONS BAYBORO, N.C.
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT EPN#__,
I hereby certify that I own property adjacent to
Name of la downer .g on
proposing development;
body of water in near
— -•
community
Lot#EF �.
Subdivision, if applicable
. • Tax Parcel # �0 8 3 off •
Complete
description of how to locate this property: OFF S,Q/3/�1
The proposed project, a location has and the
been described to me s show •in the drawing
below and I have no objections to the proposal.
FOR A PIER, CHECK ONE OF THE FOLLOWING:
wish to waive the 15' minimum setback' from my
riparian access.
I DONOT wish to waive the 15' minimum setback
requirement.
Draw the proposed structure in the apace provided Blow.
List the size of the structure and measured distances from
the adjacent property lines, other structures on the
property, and the road, water, etc.
Printed Name—, >
� Dat
Signature
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13
PAMLICO COUNTY BUILDING INSPECTIONS BAYBORO, N.C.
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT EPN#_
I hereby certify that I own property adjacent to
Name of landowner 's on
proposing development
in near ' ril7, L_
body of water community
Lot#o_ of
Subdivision, if applicable
Tax Parcel # E0 8 3 off SR_
Complete
description of how to locate this property:
Tn .i— 0--,., _ n . / - _ _
The proposed project, a i 111'X/ and the
location has been described to me s showfx in the drawing
below and I have no objections to the proposal.
FOR A PIER, CHECK ONE OF THE FOLLOWING:
I wish to waive the 15' minimum setback from my
riparian access.
T DONOT 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.
Printed N
Signature
0