General Permits (6259)

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CERTIFICATION OF EXEMPTION
1� 9
FROM REQUIRING A CAMA PERMIT r0
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
1
Address # G,
City
Project Location (County, State Road, Water Body, etc.) _
Phone Number Z 11 3 �r
State zip
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 ccrtification 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: )
A— nnrenn uihn nrnracric with a rtavalnnmant withnnt tha mn-
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.
kif
fic: f V C ,
Applicant's signature
CAMA Official's signature
Issuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

14
ADJACENT RIPARIAN PROPERTY OWNER STATEXIENT
(FOR A PIERIMOORING PILINGSIBOATLIFI'IBOATHOUSE)
I hereby certify that I own property adjacent to G-6 3DwiiGcV s
(Name of Property Owner)
property located at
(Lot,
Q" , " - (ZC3 n-
k, Road, etc.)
on P u C in q �c�5 12 , N.C.
(Waterbody) (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/boatliMoathouse 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 pmposing development)
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Print or Type Name
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Telephone Number
Date: % /AA7
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CERTIFIED MAIL 9 RETURN RECEIPT REQUESTED A Q, p„ wtofEr totyn 1,.
u�r v N.,m Z d wtt-1 aesoure"
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Individual applying for Permit: QA k ti Q Sv V.)
Address of Property: ea'l 5 5 I4 P y Q0 i vd Cp trc�
,e.
(Lot or Street #, Street or Road, City & County)
I hereby certify that I own property adjacent to the above referenced property. The individual
applying for this permit has described to me as shown on the attached drawing the development
they are proposing. A description or drawing, with dimensions, should be provided with this
letter
I have no objections to this proposal.
If ou haile objections to what is being proposed, please write the Division of Coastal
Management, Hestron Plaza II, I51B, Hwy. 24, Morehead City, NC, 28557 or call (919) 808-
2808 within 10 days of receipt of this notice. No response is considered the same as no objection
if you have been notified by Certified Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boat house, lift or sandbags must be
set back a minimum distance of 15' from my area of riparian access unless waived by me. (If you
wish to waive the setback, you must initial the appropriate blank below.)
I do wish to waive the 15' setback requirement.
V--L I do not wish to waive the 15' setback requirement.
/3
Sig ture - Date
Print Name
Telephone Number With Area Code

UNITED STATES POSTAL SERVICE 111111
Official Business PENALTY FOR PRIVATE
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OF POSTAGE, $300
Print your name, address and ZIP Code here
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1� D -sox 1 SS

m SENDER:
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y Complete items 3, and 4a & b. following services (for an extra V
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pE 4b. Service Type i
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Certified ❑ COD c
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W Merchandise
0 7. Date f Deli ry w j
IU
6. Si ature (Agent)
7 0
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X • (!, and fee is paid) c
>� Form 381 1, December 1991 *U.S. GPO: 1993-352I714
�, DOMESTIC RETURN RECEIPT

P OS6 366 428 1F� Act
US Postal Service
Receipt for Certified Mail
No Insurance Coveraqe Provided.
Do not use for Intemational Mail (Sqp reverse
nt to
reet & ber�
Po e, State, &ZIP Code
Postage is
Certified Fee
1-3
Special Delivery Fee
Restricted Delivery Fee
Retum Receipt Showing to
Whom & Date Delivered
1/0
Return Receipt Showing to Whom,
Date, & Addressee's Address
TOTAL Postage & Fees
$
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Postmark or Date
d