General Permits (6422)

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CERTIFICATION OF EXEMPTION o�
FROM REQUIRING A CAMA PERMIT 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 Phone Number
Address
City State
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.
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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.
Applicant's signature "
CAMA Official's signature
Issuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

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ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
ertity that I awn property adjacent to:
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property located at.:
near (water body)
in (county)
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The applicant described to me as shown below, the he/she is proposing in that location and: development
I have no objections to this proposal,
I do have objections to this proposal
Description and/or drawing of proposed development;
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Signature:
Name: eS57 L �d [ E "ar
Phone Number:
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StNUtFi: 1 also wish to receive the
■Complete items 1 and/or 2 for additional services.
■Complete items 3, 4a, and 4b. following services (for an
■ Print your name and address on the reverse of this form so that we can return this extra fee):
card to you.
■Attach this form to the front of the mailpiece, or on the back if space does not 1. ❑ Addressee's Address
permit.
■ Write"Return Receipt Requested' on the mailpiece below the article number. 2. ❑ Restricted Delivery
■The Return Receipt will show to whom the article was delivered and the date
delivered. Consult postmaster for fee:
3. Article Addressed to:
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4a. Article Number
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❑ Registered 'Certified
❑ Express Mail ❑Insured
❑ Return Receipt for Merchandise ❑ COD
7. Date of Delivery
8. Addressee's Address (Only it requested
and tee is paid)
Ps o 3611, December 199 102595-97-B-0179 Domestic Return Receipt

UNITED STATES POSTAL SERVICE First -Class Mail
Postage &Fees Paid
uSPS
Permit No. G-10
• Print your name, address, and ZIP Code in this box •
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Z 059 188 501
US Festal Service
Receipt for Certified Mail
No Insurance Coverage Provided.
uo not use for International Mail See reverse
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Street & Number
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Posj qffice, State, & ZIP Code
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Postage
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Certified Fee
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Special Delivery Fee
Restricted Delivery Fee
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CERTI D AI * RETURN RECEIPT REQUESTED ©. Dep.h""'wr`of rmR rrt,
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Individual applying for Permit: ��7 7— Zdz) 7e2—
Address of Property:— 7 7 `'iUi D� ��,/,r�(yi s� e2.-,
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(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 havebjections to this proposal.
If you have objections to what is being proposed, please )vrite the Division of Coastal
Management, Hestron Plaza II, 151B, Hwy. 24, Morehead City, NC, 28557 or call (919) 808-
2808 ivithin 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.
I do not wish to waive the 15' setback requirement.

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ADJACENT RIPARXAN PROPERTY OWNER STATZ24ENT
I hereby certify that.I own property adjacent to:
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property located at: �� -7 ��
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near (water body)
f� ex ic ten:
in (county) 7 7-
The applicant described to me
he/she is proposing in that as shown below, the development
as
and:
I have no objections to this proposal
I do have objections to this proposal
Description and/or drawing of proposed development;
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