General Permits (6575)

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CERTIFICATION OF EXEMPTION
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
Address
City
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-
quiremeni,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.
Phone Number
State Zip
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: )
'k'f?.t✓ ���:., i tea,. t
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 signbitu
CAMA Official's signature
Issuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

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CERTIFIED MAIL 9 RETURN RECEIPT REQUESTED d Kh and �Ro Inc,
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Individual applying for Permit: C ,#,eA? ' x< 13, C C) 2 !i.S
Address of Property: -�4% 7 zeD
4(o,
(Lot
#, Street or Road, City & County)
ne-o �fo '
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 you have objections to what is being proposed, please write the Division of Coastal
Management, Hestron Plazas H, 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 t9 waive the setback, you must initial the appropriate blank below.)
x ( I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
Signature Date S G E fi r7-Ac#,ro
vY e e-e S/1 6-'Z-rd� M�� � � s k ' rC H
Print Name
x4�1L- J--�'y-o635-
Telephone Number With Area Code

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'CX�' CERTIFIED The North Car "
AIL TURN RECEIPT REQUESTED d,A DePaft—t of E-nro—ert.
ui% Hea[h and Nate l Resoa ces
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Individual applying for Permit: CIRRAL a • �j U s
Address of Property: 3717 ��N�L Xa h�a
(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.
t4
If you have objections to what is being proposed, please write the Division of Coastal
Management, Hestron Plaza II, 151B, 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.
I do not wish to waive the 15' setback requirement.
Si e Date
A/ha) k; SEC 19 7T,9c H,E D
Print Name S KF T C H
Telephone Number With Area Code

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