General Permits (5623)

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Applicant N
Address _
City
'� 9 i
CERTIFICATION OF EXEMPTION
FROM REQUIRING A CAMA PERMIT ' _ 7W
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.
Phone Number rl 1
II State Zip �, 2
Project Location /}County, State Road, Walter Body, etc.) 6� -► "t
j
The proposed project to be located and constructed as described This certification of exemption from requiring a CAMA permit is
above is hereby certified as exempt from the LAMA permit re- valid for 90 days from the date of issuance. Following expiration,
quirement pursuant to 15 NCAC 7K .0203. This exemption to a re-examination of the project and project site may be necessary
CAMA permit requirements does not alleviate the necessity of to continue this certification.
your obtaining any other State, Federal, or Local authorization.
SKETCH �" j,R /979 (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.
Appl�canr signature
,I AF-fA I
CAMA Official's signatur4K
f -.
Issuing date
1
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

ADJACENT RIPARIAN PROPERTY ONNNER STATEMENT
(FOR A PIERIMOORING PILINGSIBOATLIFT/BOATHOUSE)
I hereby certify that I own property adjacent to 's
(Name of Property Owner)
property located at / C ±1 �✓;
(Lot, Block, Road, etc.)
on �! ' i (/��
�7�h-- �� � th 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/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 PROP.OSED DYELOPI-v�TT:
(To be _{fled in by indhdd prnposin? deve p eent)
7-
Signature
Print or Type Name
3q �E3--3"
Telephone Number
Date: /`�/G i

111999�H285 B�A�L'B�
SAC I�„S ARPROPERTY 0IN �. STA DMNU
lER/�t04RlNG PILINGSISOArUFTMIATROUSL;
F02
I hereby certify
property located at
1qu"— ,Wj
►►./
He has describe
locatluII, and, I have
p Um & s/ boat Ii tV boa t h
of riparian accxss unles
V I do not
I own property adjacent to % 's
(Kum of Property Owner)
Ut, Stock, Roa , etc.
in .d-M, 4� , N. C'
(Town andior County)
to me, as shown below, the development he is proposing at that
0 objections to his proposal. I =dcrstand ihU a pierlmooring
m>>st be set back a minimum distance of fiRva feet (15') from my arm
waived by me.
fish to waive the seftcr 7'equirement
I dQ wish]to waive that setback requirement.
DESCRIP'nON
(To
ALND/OR DRA WLNG OF FROPWED DEVELOPMENT.
le JU(ed in by Wividuol proposing developmznt)
SA 'r <
<axi-
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!St 2kt4. 'U'd..a t.-.
signature
Print or Type Itiaix
Telepbone Numbe~
Dace:`r-