General Permits (6099)

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
City State
Project Location (County, State Road, Water Body, etc.)
Type and Dimensions of Project
Phone Number
Zip
The proposed project to be located and constructed as described
This c^. rtification of exemption from requiring a CAMA permit is
above is hereby certified as exempt from the CAMA 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
(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.
.. .. . ........... ................... ....... .
A —
s signature
CAMA Official's signature
Issuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203
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ADJACENT R-11PARIAN PROPERTY OWNER STATEMEM
r
I hereby certify that I own property adjacent to 6MES KU 1r- EoMotJSTONI's
(Name of Property Owner)
property located at % q-6 N
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(Lot, Block, Road, etc.)
on in , N. C.
(Waterbody) �own�ald/orCounty)
He has described 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 DEVELOPMENT
I (To be filled in by individual proposing development)
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Telephone Number
Date: S �/

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SURVEY FOR.'
d"ES K. EDMONSTON--RONN/,E S. EDRONS
�Tp RETRACEMENT AND RHYS/CAL SURVEY
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REGISTERED LAND SURVEYOR SE107FM9ER 8,/994 SCALE.' / =60'
L-3151 NORTH CARO(JNA ✓J F/LE# 940424
1210 ARENDELL ST. (THE LAW BULDING)
PO BOX 3492, MOREHEAD CITY, NC 28557

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I hereby Certify that I own property adjacent to 'J' ftm�Fs KL,t iZ—k �Qn�c,j_S'1'��i's
(Name of Property- Owner)
property located at ace �� [
(Lot, Blocky Road, etc.) -- _
on LL ► D6E J'GfL in
(Waterbody) (Town , N. C.
an or County)
He has describers to me as shown below, the development he is proposing at that location,
and, I have no objections to his proposal.
DESCRII''I'ION AND/OR DRAWING OF PROPOSED DEVELOPNIEyT
' (To be filled in by individual proposing development)
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Telephone Number
Date: -5.1� / /9

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AR IA
REGMTERED LAND SURvVfOR a
ti L-3351 NORTH CARCURA r✓j
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PO BOX 3492, MOREKAD CITY, NC ZBW71
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F11-11 940424

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
- * (FOR A PIER/MOORING INGS/ A IFT/BOATHOUSE)
O1��'L�s
I hereby certify that I own property adjacent to I<Lkr-t EJ s
(Name of Property Owner)
property located at / (C dJiciiacc +��au f;`-�—
(Lot, Block, Road, etc.)
on ? rf_L in
l�rulsfr`t,�S � , N.C.
(Waterb y) (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 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)
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Print or Type Name
Telephone Number
Date: 7