General Permits (5646)

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CERTIFICATION OF EXEMPTION
FROM REQUIRING A CAMA PERMITS �o
as authorized by the State of North Carolina,
Department of Environment, Health, and Natural Resources and the Coastal Resources Commission R
in an area of environmental concern -pursuant -to 15•NOAG-Subchapter-7K .&203:
. - Applicant Name �% 1, � �r �-- .J �= G�'�`ti �� /W
Address
city j T7, ,, "/"/
Project Location (County, State Road, Water Body, etc.)
Phone Number - Y-U-- / 9 /i
State .4' C
T to
Type and Dimensions of Project /'I" "- ew '
zip .s
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 CAMA permit re- valid for--Wdays from the date of issuance. Following expiration,
quirement pursuant-ta 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.
I SKETCH (SCALE: trD/Re ) I
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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 signs ure -' v - / r
(%. 1�� j(
CAMA Official's signature
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Issuing date _
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

ADJACENT RIPAI T PROPERTY ONN NER STATEMENT
(FOR A PIERIMOORING PILINGSIBOATLIFFIBOATHOUSE)
I hereby certify that I own property adjacent to 6-� i 1q; 's
(Name of Property Owner)
property located at
(Lot, Bgwk, Road, etc.)
on L. , in , N.C.
(V aterbody) U (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)
0
Telephone Number
Date:

AD ACE'NT RIPARLALN PROPERTY ONN NER STATEhffiN1'
(FOR A PIER/A100RING PILINGSIBOATLIF IBOATTIHOUSE)
17wzv/
I hereby certify that I own property adjacent to �� i It (7ef4 �� 's
(Name of Property Owner)
property located at
(Lot, Block, Road, etc.)
on�.eu��� ���_ , N. C.
aterbody) 1 (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
pill ngs/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)
UA
Signs`y�s��7
Print or Type Name 1�
i
Telephone Number
Date:

Permittee's Name erm1t o N
t
Fi
'Location: eld Re 2 (�� P
Phone:
Description of Project:
Date Project Reportedly Complete:
rDate of Report: u
(1)- Do the measured dimensions of the developm iffer from those
indicated in the permit .and kplat? Y s / No Have all permit
conditions been satisfied? (Yes / No
1. COMMENT:
(2) Sedimentation and Erosion Control: Has permi =_e seeded, grassed,
or otherwise stabilized all disturbed areas: e / No
COI��NT:
(3) Future Monitoring and Zn force
or enforcement action needed?
COMMENT:
Yes
Is`further investigation