General Permits (5629)

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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
Citv
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.
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.
Phone Number
State
Zip
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.
Applicant's signature
CAMA Official's signature `-
Issuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

Monday, January 05,1998 10:45:42 PM
Page 1 of 2
ADJACEINTF RI PA.RMN PROPERTY OWNER STA. M E T
(FOR A PIE7Uc1•,fOORING PILINGSIBOATLXMBOATHOUSE)
I hereby certify Ethat I own property adjacent to ,I et+ C. P-4!4Wc,J 'S
(Name of Property Owner)
property located at o a c, P t,'%
(Lot B o,c2 k, Road, etc.)
aterbcsdy} (Town and/or County)
He has descnibui to me, as shown below, the development he is proposing at that
location, and, I have no objections to ius proposal. I understand that a pierlmoorinb
pilings/boatliftlboathouse must be set back a minimum distance of fifteen fe t (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 requiierncnt.
DESCRIPllON ANIXOR DRANYING OF PROPOSED DEVELOPMI,NT:
(To be filled in by individual proposing development)
<�110-a Via N P r, S � r-
'Signature
not or Type Name
Telephone Nurnbcr
Date:

' Monday, January 05, 1998 10:45:42 PM Page 2 of 2
ADJACENT RIPA_R AN PROPIXFY OWNER S`i'AUME, N'I'
I hereby certify that I own property adjacent to Im G+
(Nance of Pro ertp Owner)
property located at UQ j l�brl L1 < Lr\
(Lot, Bllck, Road, etc.)
on l oG i,rx �., in _mac,_ �w�•` N.C.
[Water edy) (Town and/or County) �
He has descnbed 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 DEVELOPMM
(To be ,filled in by individual proposing development)
C'(ice l a (� -"M f ' bjam'I�
�J
l
Signature /
4.
Print or Type Name
�'Cl - 393 -
Telephone Number `
Date_ 4-13 e, l r ,�--7