Jessie Lloyd Strickland III

,
' 0CERTIFICATION OF EXEMPTION
FROM REQUIRING A CAMA PERMIT
as authorized by the State of North Carolina,
0 Department of Environment,Health, and Natural Resources and the Coastal Resources Commission
in an area of env). nmental oncern pursuant to 15 NCAC Subchapter 7K .0203.
Applicant Name -9 1 ��
C ` W^^ rr� Phone Number ( JO 3(--(,&20
Address - • ©& =E
City VO Pi' State Zip L3
Project Location (County tate Road, Water Body, etc.)
r. d
Type and Dimensions of Project7�-- C/ Z!) l
The proposed project to be located and constructed as described This certification of exemption from requiring a CAMA permit is
above is hereby certified as exempt from the CAMA permit re- valid for 90 days from the date of issuance. Following expiration,
quirement pursuant to 15 NCAC 7K .0203. This exemption to a re-examination of the project and project site may be necessary
CAMA permit requirements does not alleviate the necessity of to continue this certification.
your obtaining any other State, Federal,or Local authorization.
SKETCH (SCALE: PV'TS )
CM? ( 1, r � ✓
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Any person who proceeds with a development without the con- 0.•,./'% .
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
;ertifies by signing this exemption that (1)the ap Issuing date
£d and will abide by the conditions of this exemp-
Jvritten statement has been obtained from adjacent
;ertifying that they have no objections to the Expiration date
k.
Attachment: 15 North Carolina Administrative Code 7K.0203

AGENT AUTHO'<EAU.N FOR CA\1A PERW T APPLBC TIION
Name of Property Owner Requesting Permit: Jessie LI o d Sfr;c kla ici
,I
Mailing Address: ' o t 3 G-10 a c e_5+2 r0.d
'OcK iVtoart� W 27803-1 i ['-�
y
Phone Number: qt0 I -- 2. 0
Email Address:
I certify that I have authorized P(? Y'Y'E I I Er7, L c t/-jo .e Ma 1"L►��
Ag t/Contrzor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: 5•e 2 W a I I re ra l Y'
' r
at my property located at '344 B roadvNa St SO r' ( t 17 t Y C 28, `i 5
in On sl 0111 County.
I furthermore certify that I am authorized to grant, and do in fact grant permission to
Division of Coastal Management staff, the Local Permit Officer and their agents to enter
on the aforementioned lands in connection with evaluating information related to this
permit application.
Property Owner Information:
�® e v
/ . .ture
Tess ie._ Llo d 5-{�' �c . IQr c -
Printlr Type Name
CAW n€y
Title
izolg
Date
This certification is valid through / I

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to Lloyd S" r4 c k la rtci y .i 's
'l /4 (Nime of Property Owner)
Q `+
property located at rood way S f. , Sur z-L ' N C 2$ Lf 45_
(Address, Kot Block, Road, et . l
on (1 al , in 51-11r+ City unsIov/ Co. , N.C.
(Waterbody) (City/Tdw and/or County)
The applicant has described to me, as shown below, the development proposed at the above
locatio .
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
Sec wall repcu r
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or groin
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.
(Property 0 er Information) (Adjacent Property Owner ormation)
� �- •
Oki ItiStkala i
irrnatu e. Signature
YLtoyd SIT tcliclancl,. 3Tdi.us and Torl. SFrick)cznc1
Print or Type IVame Print or Typq Name
4-® i 3 G-1ou.ce5fer 7? xd 725 h -to Lake Drive_
Ma g Ac-dres Mailinrg Address
1Ko ' OLLY1t� NC-278o3-///'/ Elcz.abethi-own, IAC 2g337
City/State/ZipCit tat i
q o - 231 - (0 S 2. Pf 10)-g
'ie, q -J/494
Cei Telephpne Number/email address Telepj7one Number/email address
9-" Z5'- I -3D- /0
Date Date*
(Revised Aug. 2014)
*Valid for one calendar year after signature*

• ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to T. L1 o Y cd 5+ 1-
(Name of Property Ownet) , ( _
property located at Q 4 -173 Yoad Wo` S+ S(i v-F C f /c - Z- 4
ii (Address, hot, Block, Road, tc.)
on Canal f , in Si1Y-f� Ci-t dn5Iovi CO. , N.C.
(Waterbody) (City/To n and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location.
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
Sea Wal I re1 G t r
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or groin
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.
(Property Owner nformation) (Adjacent Property Owner Information)
tN •
Sonat e Si atur
L 0 yd JT-rt ✓k-� /� 6 .
str
Print or T p'e Name peName
11:01 6-IoLLC e�Y Twrf"erf
Sfreet
Mailing
ho<� esslA® NcM urngAd re(s,
r
54
/ ? /VC' Z8
City/State/Zi , • 8Q7 Crty/State/Zi 6io,
3 A e oq� s
Telephone Number/email address Telephone Number/email address
' e
Date Date*
i3
(Revised Aug. 2014)
*Valid for one calendar year after signature*