General Permits (6735)

a >�
',T U T Ole `� fi�vG,✓LiL
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.-NGAC-5ubehapter7K .-0203-.
Applicant Name r `>''� �� Phone Number ! r/�A T_
Address /
City Stated Zip P/
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- NCAG 71K-:0203. This exemption to
CAMA permit requirements does not alleviate the necessity of
your obtaining any other State, Federal, or Local authorization.
EC -
This -certification of -exemption from -requiring a- CAMA permit is
valid -for' 90 days-from-the•dat ,of issuance -Following expiration,
a re-examfnatiorrof-the-project and project site may be'necessary
-4o,continue-this-oe rtif+eation•.-
I SKETCH (SCALE: )
�...... ...t,.... nr.An witV, rinvelnnmont urithnnt thn nnn-
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
Attachments 15 North Carolina Administrative Code 7K .0203

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to,
s property
located at j y 4 �-W ( �y� , on
(Lot, Bloch:, Road, etc.)
S'.�-� ��E
in I/1E �� UL�-- , N.C.
(Water Body) (Town and/or County)
He has described to me as indicated below the development
he is proposing at that location and I have no objections
to his proposal. I understand that a pier, pilings and
dredging must be set back a minumum distance of fifteen feet
(151) from my area -)f riparian access 'unless waived by me.
I do not wish to waive that setback requirement.
I do wish to waive that setback requirement.
Description and/or drawing of ptoposed development:
(To be filled in by individual proposing development.)
-Doc-K
1 -
Jy l-- Ik aa0a
Date
14 v rA✓ y L .1,41 •rCI�c b c :1A1
n
1�
NN".. a....n
Signature
UC-wEt,` t1- Eta�t�S3—
Print Name
_ay-t - 6 0 5 t
Phone 'Number
Im

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own properly adjacent to.
AFL- GL �I �1��� �'(v8s property
located at j L�.4L �=/ �y�on
(Lot, Block, Road, etc.)
'9ogvtc -TOU vo in ��E
AC'C'ES9 �N�1 �- E ryE �iv b � , N..C.
(Water Body) (Town and/or County)
I-ie has described to me as indicated below the development
he is proposing at that location and I have no objections
to his proposal. I understand that a pier, pilings and
dredging must be set back a minumum aa:tance of fifteen feet
(151) from my area of riparian access unless waived by me.
I do not wish to waive that setback requirement.
I do wish to waive that setback requirement.
Description and/or drawing of t2_,:2posed development:
(To be filled "n by individual proposing development.)
'PC- lO./ 4 eC- jo Et 1 b r zS ' I' N. P-"
D .= D (-e CX S'7 t//d e,Atd, e-L
964 W A && 'PIAA16 C !� .
ll .Jvc.ti �.y��J
Date
i
I
4di•TN 0(j,(yL i�/TC/�Lb<�iu6j
�04 t
�EN< 1
r v o r! Lv
�^'t s&L I
v'-0
Z: ' I
Sig iature
'/4 tZ?)I u?, k. 13RawrJ�
Pri:)t Name
� H 7- ' 07�Z
Phone 'Number