General Permits (6456)

CERTIFICATION OF EXEMPTION Or �p
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 .0203.
Applicant Name l �^r �' iK-' Phone Numberv�ir�
Address ; i 1 l%
City ' "'. State 't, / zip
Project Location (bounty, State Road, Water Body, etc.) c, , / I" ` u r_d 7 &t�o Paz, 4
yJ /'"'0­�'; _i > G �� r%7��i✓, <,'r�
Type and Dimensions of Project 1 5 ' hrl
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.' f. ! (SCALE: )
f i
i
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3 �71-
i
A .,,, .. n u kh nr nnrlc with n rlavolnnmant without tha rnn-
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.
Applic�yi j$nature
0 �
CAAjA Official's signature
!7.
Issuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjoining 4dJ,¢ VI k.eS Is
property located at 6-9-21 W e-(,.U- gyp+ , N. C. He has described to me as
shown below, the development he is proposing at that location and I have no
objections to his proposal.
Description and/or drawing of proposed development: (to be filled in by
individual proposing development.)
signature
-J145
name
a Sz - -7--2-6 q 6 1
phone number
129.54
S53' 30' 0o"W yiOpp DOCK
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1 I � - Ae

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjoining L, )1d ,4 g't k-e 's
property located at a'�-n W 4 (l, N. C. He has described to me as
shown below, the development he is proposing at that location and I have no
objections to his proposal.
Description and/or drawing of proposed development: (to be filled in by
individual proposing development.)
W
name
hone umber
O
0 -�4 S
�� ul- � VL l�