General Permits (4529)

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.CERTIFICATION OF EXEMPTION
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-tNCAC SubcT apter 7K .0203.
Applicant Nam_ ePhone Number
Address_, I
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 lor 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: IV(, ) j
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.
i
Applicant's signature
CAMA Official's signature
Issuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203
C

J � t
I hereby certify that I own property adjacent to //,/, /,,Z/" V<
Is property located at
block, roa , etc.)
on l-� in � .�G� ;WAP N.C.
(water body) (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 thi pier bulkhead, groin structure
(circle one)
must be set back a minimum distance of 15 feet from my area of
riparian access unless waived by me.(I d , do not wish to
circle one)
waive that setback requirement.
Description and/or drawing of proposed development: (to be
fillein by individual proposing
` development)/ /
1/7a,1c -Zo 4/.e<SIV
( SijgJnature )
(Name)
10 (449 1 9 1
(Phone Number)

I hereby certify that I own property adjacent to
Is property located at
lot, block „ ro d, etc.)
on /I/CiS in Q / �u� N.C.
(water body) (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
T\
proposal. I understand that this pier';" bulkhead, groin structure
(circle one)
must be set back a minimum distance of 15 feet from my area of
riparian access unless waived by me. I do, Cdo no wish to
(circl e)
waive that setback requirement.
Description and/or drawing of proposed development• (to be
filled in by individual proposing development � .
A/,WS % (/ 74
(Signature)— ZL z3a-tt s
(Name) f
�77T
(Phone Number)