General Permits (6796)

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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 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 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: )
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.
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Applicant's signature
CAMA Official's signature
suino date
Expiration date
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Attachment: 15 North Carolina Administrative Code 7K .0203

ADJACENT RYPARiA.N PROPERTY OWNER STATENEDU
I hereby certify that I own property adjacent to #� / �2 t i 11h w -) f`" is
(Name of Property Owner)
property located at _4 c /W,.i /' I%
(Lot, Block, Road, etc.)
on '� ;= 's c' %� f �'� %2 , in e r<' ii: "; i is N.C.
(Waterbody) (Town and/,or County)
He has described to me as shown below, the development he is proposing at that location,
and, I have no objections to his proposal.
DESCRnMON AND/OR DRAWING OF PROPOSED DEVELOP MNT
(To be filled in by individual proposing development)
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Print or Type Narre
TelepSoni Number
Date: 0 1` C

UNITED STATES POSTAL SERVICE
First -Class Mail
?i4tage & Fees'Paicl
lisps
Permit No. G-10
• Print your name, address, and ZIP Code in this box •
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v4nde1meve. NL A1�'6S`I
1,s111111111111111111if3Iffil III

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■Complete items 1 and/or 2 for additional services.
I also wish to receive the
•Complete items 3, 4a, and 4b.
following services (for an
■ Print your name and address on the reverse of this form so that we can return this
extra fee):
card to you.
■Attach this form to the front of the mailpiece, or on the back if space does not
1. ❑ Addressee's Address
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permit.
■ Write 'Return Receipt Requested' on the mailpiece below the article number.
2. ❑ Restricted Delivery
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■The Return Receipt will show to whom the article was delivered and the date
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delivered.
Consult postmaster for fee.
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3. Article Addressed to;
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WI h STb rt Silem NSA 716b
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4a. Article Number
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4b. Service Type
❑ Registered Certified
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❑ Express Mail ❑ Insured
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❑ Retum Receipt for Merchandise ❑ COD
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7. Date of/O live
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8. Addressee's Address (Only
i quested
and fee is paid) r
PS Form 3811, December 1994

DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNIER NOTIFICATION/WAIVER FORM
Name of Individual applying for Permit
Address of Property:
G3 k jZ'�/r*1- (T)R o treet J, WtZr/Road, City & County?
I hereby certify that I own property adjacent to the above rcfeicni :cd prupcity. 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 Plaza II, 151-B, Hwy. 24, Morehead City, NC, 28557 or call (252) 808.
2808 within 10 days of receipt of this notice. No response is considered the same as no objection
if you have been noiffled by Cemified 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.
Signature Date
Print Name
Telephone Number With Area Code