General Permits (6769)

—Y— CERTIFICATION OF EXEMPTION
FROM REQUIRING A CAMA PERMIT ✓V
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 Zip
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 c^rtification 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.
I SKETCH (SCALE: ) I
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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 signatures_
CAMA Official's signature
Issuing date
piration date
Attachment: 15 North Carolina Administrative Code 7K .0203

ADJACENT RIPARIAN PROPERTY OWNER STATENIENT
I hereby certify that I own property adjacent to
(Name of Property Owner)
property located at �9 SEA
(Lot, Block, Road, e*c,) '
in
C� ,
(Waterbody) N.C.
(Town and/or County)
t1e has described to me as shown below, the development he is proposing at that location,
anti, .oa ve no objections to his proposal.
ESCREMON AND/OR DRAWING OI :f1 RQ;`1')STD DEVELOP.NMN-T
(To be filled in by individual pTU>���%;�� �pvelopment)
Signatur
Print or Type ame
—1 -�I
Telephone NumOL'V),-,
be:
Date: ' 5 . 60

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to J�v 4E—A/ /,) E /ZS,)
(Name of Property Owner)
property located at %� �I-C_E /,A/
el (Lot, Pock, Road, etc.)
on 0 - - � � ✓�' �� � —%_
(Waterbody) ' N.
(Town and/or County)
He has described to me as showi, be'ow, the development he is proposing at th«t
and, I have no objections to his
DESCRIPTION ATY. 1/ . LAG Or PROPOSED DEVELOP'VL,
(To be f /ed c v t •?.dual proposing development)
Signature
ry
Print or Type Name
Telephone Number
Date:

ADJACENT RIPARLAN PROPERTY OWNER STATE�rENT
I hereby certify that I own property adjacent to ��_ 1 7s
/ (Name of Property Owner)
property located at
(Lot, Block, Road, efc,) '
on
(Waterbody) , N.C.
(Town a�dlor County)
:1e has describers to me as shown below, the development he is proposing at that location,
an+1, s.�a7fl, no objections to his proposal.
I:-SCRIPTION AND/OR DRAWING- OF ;M)'. 0SFp DEVELOPMEENT
(To be filled in by individualr; reveloprnent)
Siynature
J . V , t-y n d �&r s cad
Print or Type Name
2-5 z- -7 z 4- C� -14
Telephone Numbe:
Date: .��

ADJACT1' 1' RIPARIAN PROP.ERTY OWNER S',,: IY9-r1T
I heaeby certify that I own property adjacent to t 11,9 -12 XD
I
property�NaYm? of 1'roperty Owner)
c�;atP,d 3t � �� � S� /� �`
__ -- ���
_�,^� /� (Lot, BIock, Road, etc.)
on _ �G" (1 CJ _ s e �_ , in ( 6L_C
(N- terbody) N.C.
(Ta�:1��/r.:. County)
described to me as shown below, the de;elc i ripv.�, hP is proposing at that location,
.1io objections to his proposal
,)(- M'ION AND/OR DRAWING 0: j � .; :,.�� T,EVr_LOP'YIE' T
(To be filled in by indiMvn; . o p;nent)
�j
e
Signature
Print or Type Name
6. F6 98/
Telephone Numbe:
Date: IovG 3 U