General Permits (6870)

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CERTIFICATION OF EXEMPTION Cf"rui::,,J
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 - � 37�,il'
Address
City State ,JC. Zip 7>,5c, �7_
Project Location (County, State Road, Water Body, etc.) , n> i� :vr� c� . ✓
Type and Dimensions of Project
"J
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.
I SKETCH (SCALE: E: ) 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.
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Applicant's signature
i x� 'IV r_
CAMA Official's signature
-3c_) f i� e �y 0 f
Issuing date
Expiration date
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Attachment: 15 North Carolina Administrative Code 7K .0203

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22 2 0 0 OM 1222PM6 ANC DIV OF COASTAI1GIN1 FAX N04 25-2247333ON o - 1610 p . 2/2, 02 ]
AJUAN
f
hereby cert.Xfy that S ewn PrcpWy adjacent to g
(Name of Property O'Wrier)
ProPot7
(waterbody) (xoYn �zad(or Count a
He has d bed to me, as shown below, the dcvelopme-fit 11c is propo3in= at that location,
mod, I havr. a¢ objections to hia proposal. T understand t�.a[ a pier/mooring
pz'wl slboatliftl`u�at�nuse must be y[ back a. minirt►UM .4 z=ee. Qf f.fteen foes (15 `1 f'ro. my area
o zaaxiz arc�ss �F}less, waived by me.
I dg n t wish to waive the setO;,ek requirement_ ,j;
I Ift wish, to waive that setback requirement.
,DESC-glYrION .AND(OR DRAWING OF pRopoSFD 7DEy)EL0prvTEI'rT;
(To he fated #rt b_y indiifdkt f propaszrzg develaprnvd)
Print or Type Name
Telephone Numbcr
Date:

24 00 05:30P TWIN RIVERS FAMILY PRAOTI 252 63G 5305 P.1
A24. ?00N,10i�o 18Q6 P ?%02
-.,6 All HC. PIV OF COASTAL'MUNT FAX NO, H22473330
(,f3RnPIE COPING PILINGSIBOAT-LIF'1J2'3t)AI'ROU,�L)
I hereby certify that I own property ad}acent to ! /
�t (Naxne of P�-Dperty Owner)
property lccatM ai
t ot, Pt c , Road, etc.)
on (Wa lixrbody) Town anti/or Cnunty }
r<�s desLril�ed tta me, as shown below, the development he is proposing at that location,
his proposal. i unaerstard that a pier/mooring
a.nd, 1 have no objections to area
pilin�slboat'Wnlbnathov must he set back a minimum diStZP.CC Of f-f Oen feet (ir') from any
of ripa i;iri arce,s un'!ess waived by me.
wish to waive the Setback requirement. .
I jq wish to waive Ihzt setback requirement.
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DESCRIPTION AND/OR DRAWLNG OF PROPOSED DEVELOPMENT.
(7'o he ,died to by individual proposing developmew)
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