General Permits (7853)

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CERTIFICATION OF EXEMPTION
_Y 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
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.
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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
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
Issuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

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Customer Job Requiretment Worksheet
Customer Name _ Date DO
Mailing Address site Address
�C�g�1 on
Phone#
Fax#
Adjecent Property Owners
Left side Right
Date Mailed Returned - Date Mailed-Returned-2 -
Cert. Mailed Returned Cert. Mailed Returned
State (CAMA)
City
County t%f
Fairfield Harbour
Permit Required
Recieved
Recieved
Recieved
Recieved
Job Type
Bulkhead, (Sc), Vt
Dock
Boatlift
Jettie
Boathouse
Jet Ski Lift
Ramp
Piling

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Z02
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to 1-- KC9 Q01—[ T -s
(Name of Property Owner)
property located at
(Lot, Block, load, etc.)
on P F-Ls r i2, rH , in bi � 12 i-go �. C r1B�,
(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.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(To be filled in by individual proposing development)
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Signatuk'
Print or Type Name
Telephone Number
Date:
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08/02/00 14:43 FAA
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to
(Name of Property Owner)
property located at �2 L. Io 6,1,0 C,�Aoat gg. -
(Lot, Block, Road, etc.)
on &A —,in hJ &.6 6) C /?Bu 1Z-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.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(To be filled in by individual proposing development)
NiGv✓I /2' J) H
OR
X�17gture
Print or Type Name
Telephone Number
Date:

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