General Permits (4700)

31
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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 15 NCAC Subchapter 7K .0203.
Applicant Name
Address
City
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.
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.
Phone Number
State
Zip
This ccrtification 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.
CAMA Official's signature
ssuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

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ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIERIMOORING PILINGS/B0A7ZIFT/B0ATH0USE)
mfU 1999
I hereby certify that I own property adjacent to, , /lam / is
(Name of PropertOwner)
property located at I Vl
, Road, etc.)
on Q o G ue- S n k ,vc i s 4j , in A� o r/ 0/ 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 (15') from my area
of riparian access unless waived by me.
/U I do not wish to waive the setback requirement.
�V
I do wish to waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
Signature
4 16�s
Print or Type Name
Telephone Number
Date: �-) ' % D

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ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIERIMOORING PILINGSIBOATLIFT/BOATHOUSE)
I hereby certify that I own property adjacent to % ,113 k A,,� e / A c
(Name of Prope y Owner)
property located at
LJ
Road, etc.)
on ,T F OP Soot j- , in �ci � � �c�.�� , 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 (15') from my area
of riparian access unless waived by me.
AM I do not wish to waive the setback requirement.
A
I do wish to waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
ignature
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Print or Type Name
Telephone Number
Date: /

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