General Permits (6455)

r CERTIFICATION OF EXEMPTION o
FROM REQUIRING A CAMA PERMIT /u
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.
?9'
Applicant Name c'4 Phone Number's s_%=
Address
City ,,, ,;��r f; State zip ez-
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.
SKETCH (SCALE: )
j r
1
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

s � i • • • • � • • � ail _ � t 1!. _
I hereby certify that I own property adjacent to ROOF ? D,
.
•
property located at Ak—lu
(lot, block, road, etc)
on M oo—r- :�, C 4-EE:14, in ►lit �i2-� : -r-
(body of water) (town)
North Carolina in �A mi,C"c� County. The proposal has been described to
me as shown below; the development, a( /bulkhead/structure, and the
(circle one)
proposed location, and I have not objection to the proposal. I under-
stand that if the development is a pier, it must be set back a minimum
distance of 15 feet from my area of riparian access unless waived by me.
I do d of wish.to waive that setback requirement.
rcle one)
Description and/or drawing of proposed development: (to be filled in by
individual proposing development). INDICATE THE SIZE AND LOCATION OF THE
STRUCTURE AND THE DISTANCE BETWEEN EACH PROPERTY LINE AND THE WATER. --
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(Original must be retained in the Inspection Department)
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triyn A tune
Date
/c>Aac- - E/::f o Cry o
Name (Plda a Print)
\
C1c t//�✓ i 5 h0� / 3 9A -r tc L
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09/19/97 FRI 08:01 FAA 633 5775 W4ATERFRONT PROPERTIES 9 002
SEP-19-9 7 4.77:32 PM F•. 0
SEP-LB-97 QQ.LL rROM: kDl 7 rAGE 3/3
aTA m�rRyw*
hereby certizy that I o+.?n propexty aia aa:QL,saL to
lot i7T:1t";-_, road, etc; 04LWAm L .�r
on a n�ls
Rcsrttt. Caralsna, in `C� Cu�uLLx _ iuG psoposa.. ."a yimii1 o
te. as ghown helov- the dtvelopmant, �i ,a ,G anu LIe
(ciarcze one)
proposed locat lart, a*tft i have not. chloctia_► to cne propo"I. i under-
atand zhat It 'thA dovelopment is a pier, it must be set back a minimum
distance of Ili feast fzrna mY area of riparian accasn unless Wa i:rad by me.
Y 4 oLc� '� w:itih to waive that satback requirement.
(circle tmla)
ifi�iir&ir#ieif=xe=r:lxiZ:.:.44.Q11114-LA**A*73rit; **,L 4-
1�r{r$�+yidtraeli3
oaecrlption and/or drauinq of proposed davajopzanz- (to be fillad in by
Individual. proposing devetlopmenr.j . 7LRDYL.;,A & !A 3�:,� Al=D 4. ": ;ON Or TFE
STRUCTURE AND 'TWE DrSTANCE BSTWERN EACH PROPERTY LII?Lr AND THr. WA.TER-
1 • l'x�.7 T •i b=�-�,:6`'�[.o "j' !�"� Ac r�.?�. bla�ro�
CS
f '` ` 11,QL ,t tA
L
+�
::t:
( r g�nal mutt be retained in the Tris ctfen Department)
gnaturm
Date
Dmald 4 - e -re
N e (Pleaas Print)