General Permits (7096)

CERTIFICATION OF EXEMPTION {�
FROM REQUIRING A CAMA PERMIT
• as authorized by the State of North Carolina, �p
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 �� ! i Y - Phone Number
Address
City A 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: )
I
I
I -� I • v
1
i
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.
Mppiivan[ s 5/i`gnarure
CAMA Official's signature
Issuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

fo
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT (FOR A PIER)
I hereby certify that I own property adjacent to LO( -Linn,
property located at L-U- * -PL i4 N T t9'71 0 iy
(lot, block, road, etc.)
on t��y u� S C U b in C � �-�- N.C.
(water body) (town and/or count
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 must be set back a
minimum distance of 15 feet from my area of riparian access unless waived by me.
I do / do not wish to waive that setback requirement.
(circle one)
Description and/or drawing of proposed development
proposing development)
by individual
(to be filled in
C) K
Si nature
F�
Name
'7z ?t07
Phone Number
So'

RU5-10-94 21:00 .TR1ILLER TEL:818F*37-1825 P:01
F
Nlk
AUG-02-1994 12:49 FROVI MCPEHEAD CITY POLICE
TO 102880S1888?i8 JS301 P.02
ADJAG'ENT RIPARIAN rROPERTY OwNzR STATEbMNT (FOR A PIER)
1 hereby certify that I awn property adsac:eiit to L) iL"41n &C92MSLr-Ys
property located at �. a sO
� t� (lot, block, road, etc.)
art t;-�s 0u.kIF - t [�.�.+ ill Q_82 TER� , N.C.
(water body) (town and/ar county)
He has described to foe as shown below the development he is proposi-P9 at that location
and ) have no objections to his proposal. I understand that a pier must be set back a
minimum distance of ib feet from my area of riparian access unless waived by rne.
0 d a wish to waive that setback requirement.
(circle one)
Description and/or drawing of proposed development: (to be filled in by individual
r
proposing development) p'z.k
g•7 .-i fo t
5i tore
Name
�r 50
-P-home- Number
1� f'tj_L6q