General Permits (6820)

CERTIFICATION OF EXEMPTION L�
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k-� FROM REQUIRING A LAMA PERMIT � `a
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-
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.
Phone Number 2,+�.i - 2.tio
State Zip 7 ; 05-71
This cc tification 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.
sent of a CAMA official under the mistaken assumption that the Applicant's signature
development is exempted, will be in violation of the CAMA if there
is a subsequent determination that a permit was required for the
development. CAMA Official's signature
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.
Issuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSIBOATLIFT/BOATHOUSE)
I hereby certify that I own property adjacent to f1/ z- 6 /'V N �/s c I
(Name of Property Owner)
property located at o C /:2/-// --� fol "'✓ r e o
(Lot, Block, Road, etc.)
on /t/ Uy ee K / J r 4 , in b /�/Lr� % W 4- , 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. I understand that a pier/mooring
pilings/boatlift/boathouse must be set back a minimum distance of fifteen feet (15') from my area
of riparian access unless waived by me.
I do not wish to waive the setback requirement.
I d-Q wish to waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
j✓C7:-axer X(VO12
X JG/C 4j,¢ 66
Print or Type Name
Telephone Number
Date:
1//_) v4 4,) 4( c c

DEC-28-1999 07:51 MATHEWSON EQUIPMENT 401 231 5730 P.01ii02
Ai%JACENT RWARLAN P`RACiPERTY OWNER STATEAIMT
I hereby certify that I own property adjacent to C u 's
(lame of Property Owner)
property looted at ,P'a" F'�'r /`'�`�i✓ �K'v /�
(JAA, Block, Road, etc.)
on /t%�afC-r' lI/f.'E'-t , in 4 / j , N.C.
�. (Waterbody) (Torun andlor County)
He -has described to me -a -shown below, the4evelopment he is Proposing at that location,
and, I have no objections to his Proposal.
DESCRUMON AND/OR DRAWING OF PROPOSED DEVELOPMENT
(To be fiUed lu -by in&vidual proposing development)
,,4 ,OfTi1F,) fo✓
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Sianature
61
Print or Type Name
of-ffs-- �2 -5-s-
Telephone Number
Date* a

'ENDER:
.Complete items 1 and/or 2 for additional services.
■Complete items 3, 4a, and 4b.
I also wish to receive the
following serVtces (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 tone to the front of the mailpiece, or on the back if space does not
1. ❑ Addressee's Address
d
Z
permit.
■Write'Retum Receipt Requested' on the mailpiece below the article number.
2. ❑ Restricted Delivery
a,
N
■The Return Receipt will show to whom the article was delivered and the date
fl
delivered.
Consult postmaster for fee.
In
t bsory Pk he"s6w
C,C VI,I e Df
�r Cif eelu �,j ch ^�
5.
4a. Article Number
d
c'
¢
4b. Service Type /
❑ Registered Q' Certified
at'
❑ Express Mail ❑ Insured
H r
❑ Return Receipt for Merchandise ❑ COD
7. Date of Delivery/
'o
a
B. Addressee's ddress (Only if requested
and fee is paid)
s
3811, December 1994 vunlcbuc ncwiu nck.ciNL

UNITED STATES •POST*4VI I grp{j4 g
1*1 1 ! _C)" C49
First -Class Mail
2•(: Pa'sg*&. fa?es Paid ;1
USPS
Permit No, G-10
• Print your name, address, and ZIP Code in this box •
au c' y Short
o 20'�
�[AruG14�1Irte,' C Kc 6��5 � 7