General Permits (4884)

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,
Type and Dimensions of Project
Water Body, etc.)
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.
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
INevelopment.
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 f.
State
Zip ? ✓�-i
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.
Applicant's signature
CAMA Official's signature
Issuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

GENERAL PERMIT APPLICATION INFORMATION
APPLICANT'S NAME: h`
(First) (Middle) (Last)
M,----ING ADDRE:iS : 16 o, _ 0 U n -' cEitJ �(
Al
(PERMANENT) _ _
�� ��/� STATE ZIP
TELEPHONE: WORK ( ) HOME (c)/g) L?2
r_
CONTRACTOR'S NAME: F', �- !-d i TELEPHONE NUMBER
a
PROJECT LOCATION: N.C. Hwy. # 96 SR Road/Street Name (1-; iT'4�v
Waterway Name A)FUdX County C f?go J
Town A)EA) Subdivision �,�',yiioLy;/7.� f�i�J�r1✓Zr
PROJECT ACTIVITIES:
PIER: Total dimensions of pier from MHW to platform
(Length) (Width)
'T' or 'L'-head platform
(Length) (Width) (Number of Mooring Piles)
Water depth at end of pier.
i T HOUSE/BOr1T LIFT: Length
Number of Piles
i
Ei�
D: #1 Total length MV
Number of Mooring piles
Width
Water Depth
Average distance waterward MHW — O
Maximum distance waterward MHW p,Ir,l%/�.lL_
�/ 2 �sta3—i ng k 14) (A1- Z :T I %/) eft
Average distance waterward MHW
Maximum distance waterward MHW
RIPRAP: Total length
EXCAVATION: [MAINTENANCE 'ONLY')
Length
Width
Base width from MHW
Depth of Cut
Adjusted water depth on MLW Existing water depth(s)
Estimated Cubic Yards (length x width x depth/27)
Type of spoil: Sand Mud
Dr«gline Backhoe
Hydraul

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ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER)
I hereby certify that I own property adjacent to
's property located at
Name of Propert Owner
(Lot, Block, Road, etc.
on /V EOS IZ o iu2 , in NIZc) 471i N 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 must be set back a minimum
distance of fifteen feet (151) from my area -of riparian access
unless waived by me.
I do not �,7ish to !,7aive that setback requirement.
I do wish to waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
pi�oomy
County of n
State of
J
Notary Public
My Commission Expires:`
Signature
Print or Type"Name
Telephone Number

ADJACENT RIPARIAN PROPERTY OWNER STATE ZNT
(FOR A PIER)
jIhereby certify that I own property adjacent to
F't 's property located at
(Name of Proplezty Owner)
i3v 2 �,7J l�•A�y n. � .
(Lot, Block, Road, etc.)
N
on 1a1Q , in T �� �. , 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 must be set back a minimum
distance of fifteen feet (151) from my area -of riparian access
unless waived by me.
I do not wish to waive that setback requirement.
I do wish to waive that setback. requirement.
DESCRIPTION ANWOR D
(To be.f-lled in by i
01
O (jfiN f
� County of
Ci r-r.ter✓
State" of
r
Notary. Public
My Commission' Expires:.
WING OF PROPOS
vidual propos
I
,rint or
ED DEVELOPMENT:
ing development)
'elephone Number
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