General Permits (5647)

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 LC) Phone Number
Address r err /
City r, "' State Zip
Project Location (County, State Road, Water Body, etc.) /3K 9
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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.
1 ✓i
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.
SKETCH (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.
Applicant's signature
li "1%n
CAMA Official's signature
Issuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

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F'01SUX 776 VkM1.1C0 CUUNTI' Hij11.UING MVIAMONS BAYBOKU, N.C. 26'1"
(` !9) 745-3861
(After this forty is completed by the landowner proposing the project,
a copy is given to his/her adjacent landowners for their consent and
signatures. The forma are then returned, along with a building plan
and other applicable required information, to the Building Inspections,
Office for building permit application/processing.)
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT EPNV
WILLIAM I hereby certify
V 6P,tV A 0j�a 6-e--,.Sy nl , s
Name of landowner proposing developaent
in/ne&rA eAPA140 C ,� L L.ot 2
community
Tax Parcel 0 off sp,
that I owls property adjacent to
on ,� E US E >� I V C'c-
//%% body of water
of 6e,.ryT7,`l 13A y
Subdivision, if applicable
Complete description of how to
locate this property: AT -w& 1-�w.l)
ic-A- � ,rzz T_( , an¢ the location ha6 been The proptosed project, a %
descrit�ed tome as shown in the drawing below and I have no objections
to the proposal.
FOR A PIER, CHECK ONE OF THE FOLLOWING:
I wish to waive the 15' mi.niaua setback from my riparian access.
I DO NOT wish to waive the 15' minibus setback requirement.
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Draw the proposed structure is the space provided below. Dist the size
of the structure and measured distances from the adjacent property
lines, other structures on the property, and the road, water, etc.
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1'08OX 776 PAMLICO COUNTY 111j11A ING IN5VL(;T1UN5 BAYBORO, N.C.
[phone]
(After this fora is completed by the landowner proposing the project,
a copy is given to his/her adjacent landowners for their consent and
signatures. The forms are then returned, along with a building plan
and other applicable required information, to the Building Inspections'
Office for building permit application/processing.)
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT EPNO
` IL-L/AM 4i� I hereby certify
V 6P,fV A J_ 0 i3 CP--S O ni , s
Name of landowner proposing development
in/near f-,APA/40 L .IV Lot�l�
community
Tax Parcel 0 oft S l__3 ` .
that I own property adjacent to
on Lv E uI - V �.' I�
body of water
of__ tyre, / /-3,1 Y
Subdivision, if applicable
Complete description of how to
locate this property: LETyae /-3G y // `/ t HA,<dls 6iv'
14A ii ell / C_ a
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The proposed project, a / iE� TT _/ , an¢ the location hss been
described tome as shown in the drawing below and I have no objections
to the proposal.
FOR A PIER, CHECK ONE OF THE FOLLOWING:
I wish to waive the 15, minimum setback from my riparian access.
I DO NOT wish to waive the 15' minimum setback requirement.
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Draw the proposed structure in the space provided below: mist the size
of the structure and measured distances from the adjacent property
lines, other structures on the property, and the road, water, etc.
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