General Permits (4933)

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.
is a subsequent determination tnat a permit was requires Tor 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 f f ':'> S
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.
CAMA Official's ignature
f
i
Issuing date i j
/ Z_/
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

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ADJAC'3NT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property -adjacent to --LER(Y Y_jgR
Property locat:,d at LOT ## 10, GOOD WINDS SUBDIVI.S I d
(lot. black . road etc . )
on GREENS C$Fdfi__ —_ near ORIENTAI,L___
(body of water) - (town)
North Carolina in Pamlico County. TYL§i rias been described to met as
shown below; a development, etment, and the proposer,
circle)
location, and I have no objections to the proposal. I understand that i;f
the development is a pier, it must bc: set back minimum distance of 15 feet
from my area of riparian access unless waived by me. I_ trin n wish.�t,o
(circ e one,l
waive that set back requirement.
Description and/or drawing of proposed development. (to be filled in by
individual proposing development) INDICATE THE SIZE AND LOCATION OF THE
STRUCTURE AND THE DISTANCE BETWEEN EACH PROPERTJ LINE AND WATER.
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IIN.Ai Glwa/fNey
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101
114
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(Original must be retained in the Inspection Department)
SIGNATURE
DATE 1' h(A1M L C %Tc- T—
NAME, PLEASE PRIN'P��,_�_.

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify iha t: I own property adjacent to LEROY FERRY
property located at LOT # 10 GOOD WINDS SUBDIVISION
(lot. block road et . 1
on GREENS CREEK near ORIENTAL
(body of water) (town)
North Carolina in Pamlico Coz4gp=
een described to men as
shown below; a development, , and the proposed
location, and I have no objections to the proposal. I understand that if
the development is a.pier, it must be set back a minimum distance of 15 feet
from my area of riparian'access unless waived by me. IdSldo not wish to
(circle one)
waive that set back requirement.
Description and/or drawing of proposed development. (to be filled in by
individual proposing development) INDICATE THE SIZE AND LOCATION OF THE
STRUCTURE AND THE DISTANCE BETWEEN EACH PROPERTY LINE AND WATER.
b
L�ro� F�=rr-y Lof '�l0
fig-j=-r..�.:,�h'cfal.�✓� wall� /
41V,11 6-;�Aia/INey �l
j' l abase' Dock f- 21v"!wr;JV'
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r
(Original must be retained in the Inspection Department)
DATE
SIGNATURE
nae. s
NAME, PLEASE PRIlff___� .