General Permits (5078)

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n, CERTIFICATION OF EXEMPTION b19
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 �/r9i�l� f� ilke
Address D . /0 _t
(e1
Phone Numbers U i6 V
City r, 1 e,/ State AJ( Zip ,-f� i•
Project Location (County, State. -Road, Water Body, etc.) ham.
Type and Dimensions
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.
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.
SKETCH (SCALE: ,, )
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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.
Appli64n/t's signature 7
CAMA Official's signs re
/, -7 0- 9 7
Issuing date
Q 7
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to
's property located at `rA�n I per- DYMi lfP
�YO Q C r P n (lot, block, r ad, etc.)
i
on , N.C.
(body of water) town and/or county
The proposal has been described to me as shown below; the development, a
(:Lie bulkhead L structure, and the proposed location, and I have no objections
(circle one)
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. I do do not wish to waive that setback requirement.
Ds=ipticn and/or rawir6 proposed deW-1qr nt: (to be filled in by individual
proposing de�elcpn nt.
dY-aW,�,��
-Fro r
0-5 mod- i rt re__� P I e s)
(Original must be retained in the Inspecticn Iepartm2nt)
Signature
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Name (Please Pri )

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ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to S
's property located at JLey? i Der Pr i
�2 (lot, block, r ad, etc.)
on �llY'�a � V n� in EL)_m I I CD (-c ny , N.C.
(body of water) town and/or county
The proposal has been described to me as shown below; the development, a
ier bulkhead L structure, and the proposed location, and I have no objections
z�2
(circle one)
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. I IWdo not wish to waive that setback requirement.
LL ipticn and/draw' of � ftelop�t: (to be filler in by irrlivid zl
proposing dewelgmmt• )
s� Lx�V 4o C clr6;k_V ✓lc(
-pro asud i Yl r e-d C Imo)
(Original mast be retained in the Insp�cticn D�pattnt)
a
LkAA
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gnature
Name (Please Print)

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