General Permits (6384)

CERTIFICATION OF EXEMPTION �0
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FROM REQUIRING A CAMA PERMIT t r "' C
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 Cr° ` Phone Number
Address
City State Zip { 7
Project Location (County, State Road, Water Body, etc.)
Type and Dimensions of Project ,^ � ��,• x % " �' ✓
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 otlr 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: )
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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.
_. Aoolicant'stsionature
CAMA Official's signature"
Issuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

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BAM*+W'-COUNTY BUILDING INSPECTIONS .
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(After this form 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 q1e Building inspections'
Office.for building permit application/processing.)
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT EPN#
I hereby certify that I own property adjacent to
�1 r�SJo ?nr er C' ,Q•` �� s on eA j6,j �O rT�nr`-'Y `
Name of landowner proposing deve opmQnt body of water'.
in/nearortt�k�p _ Lot�l 3� of_ _ S O v��, S ". ,,.r-5
community Subdivision, if applicable
Tax Parcel 0le3$2/�S/�c��off SRComplete" description of how tc,
w /y
locate this property:_ / fig', v�[r' ,Q/ % lvl-�� �� %//� •
S So�-S � r r. - - 1 ST S►� � • mac. t 5 �5 �
The proposed project, a21
��J� �CAfee-
described toE me as shown in the drawin below and I have -no objocation e
ctions
ions been
to the proposal.
FOR A PIER, CHECK ONE OF THE FOLLOWING:
�i wish to waive the 15, miclimum setback from my riparian access.
1 DO NOT wish to waive the 15, minimum setback requirement.
Draw the proposed structure in the space provided below. List the size
of the structure and measured distances from the adjacent property
lines, other structures on the property, and the road. war,,- o,--
i
11i Signature

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COUNTY BUILDING 1NSPE;CTIONS
(
(After this form 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 t, e Building Inspections,
Office.for building permit application/processing.)
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT EPN#
i hereby certify that 1 own property adjacent to
on
Name of landowner proposing devel ment body of water
AA
in/near— M Lot4f 3% S�T� — S S
community of u c
Subdivision, if applicable
Tax Parcel #LMLMbnsXoff SR
locate this property:�i✓cr B(u�
Complete description of how tc,
J
The proposed project, a S�S and the location has been
described tome as shown in the drawing below and I have no objections
to th proposal.
FOR A PIER, CHECK ONE OF THE FOLLOWING:
I wish to waive the 15, mirlimtun setba
ck from my riparian access.
-001 DO NOT wish to waive the 15, minimum setback requirement.,
Draw the proposed structure in the space provided below. List the size
of the structure and measured distances from the adjacent property
lines, other struct+.li-Fc nn rho _.-.,.,,,. _ __ 1

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