General Permits (4516)

CERTIFICATION OF EXEMPTION
FROM REQUIRING A CAMA PERMIT SDP 'f
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 Phone Number
Address
City State Zip
Project Location (County, State Road, Water Body, etc.)
Type and Dimensions of Project
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: )
Mlly FJCIJUII VVIIU'./IUIJCtl UJ VVILII Ct Ut1VCIUt.JIIIOIIL YYILIIVUL LI -I-
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.
4
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Applicant's signature
CAMA Official's signature
Issuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

JL Pamlico County Building Inspections
P.O. Box 776
Bayboro, N.C. 28515
(919)-745-3861
_AdLatent RiparianProperty Owner Statement Epn#
I hereby certif}, that I own property adjacent to Q��i'esll�AM6� Is
Name of landowner proposing development
11'l�/Y'M'�S''y �fi� in/near Lot# of
Community Subdivision, if applicable
Tax Parcel #
off SR
Complete description of how to locate this roperty: c l 7�O ��,
5 CGc.�4
sr rdi.tir r�F�rva „r vrr� L.� �� i N G( /+S t56y —o-r 5
This proposed project, a q ul , 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:
►—I wish to waive tht 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.
signer this
sienaturt orm is completed by the landowner proposing the project, a copy is given to the adjacent landowners for their consent and
es The forms are then retumed. along with a building plan and other applicable required infionnation, to the Building
Inspe;;tions ()t3ice for building permit application/proeessin,
Signatur '
Date,—�_