General Permits (5284)

Applicant Name _
Address
City /,Jac
Project Location (C
CERTIFICATION -OF EXEMPTION 9,,f
FROM REQUIRING A CAMA PERMIT 41kk/
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-.Q 0.3_
Phone Number 9W-s640
Zip a7 69
7r
Type and Dimensions of Project _4-_ A-// 9R
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.
. K
fir:' ' f r :,.:
This certification of exemption from requiring a CAMA permit is
valid for 9"ays from the date of issuance. Following expiration,
a re-examination of the project and project site may be necessary
to continue this certification.
I SKETCH (SCALE: ,-;,-.- )
AV16Y6 r
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.hasbeen obtained from adjacent
landowners certifying that they.. -have-- no objections --ton the
proposed -work. 1 c a i
.m j
AINL _
L
Applicant's signature
CAMA Official's signature
Issuing date
'! J! h 7
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

ADJACENT RIPARIAN PROPERTY OWNER STA
I hereby certify that I own property adjacent to 5� Moan, is
(Name of Property Owner)
property located at
(Lot, Block, Road, etc.)
on _�Q,arlsc� �c•�vv�r— in �r,tigq/.��.y , N.C.
(Waterbody) (TCounty)
He has described to me as shown below, the development he is proposing at that location,
and, I have no objections to his proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(To be filled in by individual proposing development)
Print or Type Name
Telephone Number (�
Date: e / / / /

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to s;� JJOO lMaVre-- 's
(Name of Property Owner)
property located at
(Lot, Block, Road, etc.)
on _ l� s� �v��a- in �a�,,.� 1 �`�� , 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.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(To be filled in by individual proposing development)
�J"t�
..IQ
C= L) tt "�-o
Signature
C/-7 8 P�-6 l� • � , � � 5
Print or Type Name �—
�`li5) Z Y2- 43Z3
Telepho e Number
Date: 9 7