General Permits (4825)

1 CERTIFICATION OF EXEMPTION
FROM REQUIRING A CAMA PERMIT�,�.
as authorized by the State of North Carolina,
Department of Natural Resources and Community Development 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.
State
Phone Number
Zip 7 -!1 ,
This certification of exemption from requiring a CAMA permit is
valid for 60 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: )
/`.
�CGc�" �"'✓ Wit'- ,� � -
-77
I
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

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i hereby certify tltaL• I owil property adjacent Lo2�0'
is property located at _-I
oil (lot L► oc road, etc. )
in �j N.C.
(wnter bo y) (town and/or county)
lie has described to me as slKyni below the developnent Ile is proposing at
Lliat location and I have no objections to his proposal. I widerstand that
this aftr/bulkliead/structure must be set back a minimum distance of 15 feet
(clrcle one)
frun my area of riparian access wiless waived by me. I do do not wish to
waive that setback requirement.
(circle one)
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Unncrlptlon and/or drnwing or proponed developmetitt (to be tilled
in by indlvidunl propooing developmon ) L^G7 G3�
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1 hereby certify tliat I own property adjPC3211t to
's E)roperty located at
/ k ro*d, at .)
on inN.C.
(venter body) (to�ind/orcount
lie has described to me as ShOwn below the developinent he is proposing at
tliat location alid I have no objections to his proposal. I understand that
Uiis bulkhead/structure must be set back a minimum distance of 15 feet
(circle one)
frun my area of riparian access uliless waived by we. do do not wish to
(circle one)
waive that setback requirement.
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Unocriptlon And/or drnaing or proponed devolopmontt `(to be rllled
In by lndlviduni propooing development)
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Signa ure
Name
RA�
I,I►o per

ALUAClfill' ltll`111t111N 110121ITY (AIII-At "J'1'11'112-111TV
1 I►ereby certify UiaL- I own property adjacent Lo
is property located at
blocky ro�d� a .)
on inN.C.
(venter body) (town and/or coon y)
lie has described to me as sliown below the development he is proposing at
that location and I have no objections to his proposal. I wrderstand that
this /bulkhead/strucLure must be set back a minimum distance of 15 feet
(circle onn)
frun my area of riparian access tuiless waived by we. I do do not wish to
waive that setback requirement. (circle one)
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Unocrlption and/or drnwing of proponed devolopmontt (to be filled
In by lndividunl propooing developmont)
s
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Signature
N�-une
Phoi►e Ntmtdx--r

AtUACCt.N1' RIPAi(llllJ 1'(iUl'1�2'1'Y cxnll:t( ;;'1'l�'1'LI11 tr1'
i hereby certify drat I own property adjacent to T h4l
's is erty located at
=9block coed, etc.)C
on _ o-- in /� , N.C.
(venter body) (Loaf% nrid/or county)
tie has described to me as shown below the development ire is proposing at
that location and I have no objections to his proposal. I understand that
Uiis 4AW/bulkhead/structure must be set back a minimum distance of 15 feet
(circle one)
frcun my area or riparian access unless waived by me. I do do not wish to
waive that setback requirement. (circle one)
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Doncrlptlon end/or drnaing of proponed dovolopmor%tr (to be tilled
In by individual propooif%g developmont)
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Signature
Name
i'lrone N�n�d�cr