General Permits (5807)

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Applicant Name
Address,:a'�- '
City
Project Location (+
CERTIFICATION OF EXEMPTION 9
FROM REQUIRING A CAMA PERMIT V, ('r
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
` State Zip
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.
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: )
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.
Attachment: 15 North Carolina Administrative Code 7K .0203

. T
Location: Field Fep.
Phone: Date of Retort: 3 �
Description of Project: (�
Date Project Reportedly Comp-Itte :
(1) Do the measured dimensions of the developm-ent--di ffer
(2)
(3)
indicated
in the pernuit and
Qr plat?.
Yew/ No Have
conditions
been satisfied?
es No
COiP-�ENT :
from those
all permit
Sedimentation ane- erosion Control: Has FEr1TiEEf
or G� rlerwlsE StcZ11 i ZED all C1stlZrDE^_ are=s: /I No
COrE�EN'T :
I
crassEE,
Future Monitoring and Enforcement Ac- on: Is' further i nvesticaticn
or enforcement action needed? Yes / No-
COM�NT

ADJACENT RIPARIAN PROPERTY PVY74ZER STA
(FOR A PIERIMOORING PILING (BOATLIFT/B ATHDUSE)
I hereby certify that I own property adjacent to <G0 DV\ t ; Rf- is
(Name of Property Owner)
property located at LR f E eyAre' p U L." C
(Lot, Block, Road, etc.)
on in .ERPs 1 N.C.
aterbody) (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/boadift/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.
V I do wish to waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPML NT:
(To be filled in by individual proposing development)
s
'Signature
i A 14 n
Print or Type Name
Telephone Number
Date: 0

ADJACENT RIPARIAN PROPERTY STA
(FOR A PIERIMOORING PILIN I740AYZIWOAYHOUSE)
I hereby certify that I own property adjacent to k (=dam 'SGk i V Ar- is
(Name of Property Owner)
property located at 4a q CA PE Evvt F-RAW I--
(Lot, Block, Road, etc.)
on 'A in -Cmof AIJ 1 � �� , N.C.
Vaterbody) (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/ I do wish to waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPM=:
(To be filled in by individual proposing development)
Signature
V� �A
Print or Type Name
7 J`\-- gy-\�-j
Telephone Number
Date: