General Permits (6105)

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 .`,20��
Applicant Name Phone —Number
Address
City State Zip
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.
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.
1
I SKETCH (SCALE: ) I
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.
t i i
{ ++tj�1 -1
s sianature
CAMA Official's signature
ssuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

2 iin «-1 6 {�pp(1�sS cuP-71S 5
7 7
ADJACENT RIPARIAN PR.'jPERTY OWNER STATEMENT (FOR M �-
5vp L,-�4 LC
1 hereby certify Lha;o' . i ,vn Adjacent toC u.tz1 s
prope.rcy locar,ed al: l C;1 :5 CiDe t:lock, road, etc.)
OR
(water ices_ + (town and/or count,•)
He has described to me as shown the development he is proposing; at thliL local.
and I have no objections i.o i1i& ;,rcUosal. I understand that a pier mast be s,:t ha,
minimurn distance of 15 teec frc.r, rrr.,r area of riparian access unless waived h: ,:rr .
I do do r10t wish to waive t i1a;. r:t:; b, r:t( rf:quirement.
(circl: one)
CPscripr.Lon and/or ,ofi':?ji ,,il1 l ,leveinpment: (to he filled lrr by
proposing de-vt lopmen?;:
APR 0 9 1999
LC
Signature —_—`-------
Name
zs2 z7 Si 3
Phone Dumber

b
ADJACENT RIPARIAN PR--';6 ERT;' OWNER STATEMENT WOR A -'TM,
, -7C-00 4 LC.
I hereby cerLify that. i e..,rr r+. ;idjacent tQ :U
property located at I,:25—
_w, block, road, etc.)
c,, �;t6 w5 , U1 N
JD
(water
(town and/or count,..
He has described to me as the development he is proposing; at Lim,!
and 1 have no objections ;.,: ;;rr; Jowl. I understand that a pier must be
miriimurn distance of 16 ie-i fr,.a = area of riparian access unless valved by
o do not il-i t Cl 1r;'-� re -men et.
1cle one)
Description andior drawing „i di�velopment: (to be filled In b
proposing de velopm.eni )
? I `
lob
In
APR 0 9 1999
1 `r V v , ,
- > 1LY
Name
Phone Number

s