General Permits (5185)

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C_E_.R-TTRQAT4QkN OF EXEMPTION
FROM REQUIRING A CAMA PERMITti
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-*pwa*mant4o---- bchrapter 7t -*.1D2 37—
Applicant Name /�'rd� s
Address -;26
City f
Project Locatio (County, State Roam Wa er Bod etc.) / d
Phone Number 7i V- 2J- ?y
State Vc—
Zip
Type and Dimensions of Project 6;
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The proposed project to be located and constructed as described
above is hereby certified as exempt from the CAMA permit re-
quirement exemption to
CAMA permit requirements does not alleviate the necessity of
your obtaining any other State, Federal, or Local authorization.
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This c-�-tification of exemption from requiring a CAMA permit is
valid for 90cdays from the date of issuance. Following expiration,
a re-examination of the project and project site may be necessary
to continue this certification.
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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.
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Applicant's signature \J
CAMA Official's signat e
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Issuing date
7—J/. 1) 7
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

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ADJACENT RIPARIAN PROPERTY OV7*4R STATEMENT
(FOR A PIERIMOORING PILINGS/BOATLIFTIBOATHOUSE)
I hereby certify that I own property adjacent to C C l:) ; S 's
(Nanke of Property Owner)
property located at _ _I U A U 4 d L:, (y, N w c�
(Lot, Block, Road, etc.)
on u C �� �� G " , in c' a 0 o k T , N.C.
aterbody) (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.
I do not wish to waive the 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)
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Print or Type Name
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Telephone Number
Date: /1_"