01550D - Benson

CERTIFICATE OF EXEMPTION
FROM REQUIRING A CAMA PERMIT y 01.5
as authorized by the State of North Carolina,
Department of Environment and Natural Resources and the Coastal Resources Corn ion
in an area of environmental concern pursuant to 15 NCAC Subchapter 7K
/ l3 C/ /� " /A 1410;Phone Number /--7!2
icant Name � �- �
ess
State Zip
:ct ocat'on (County, a oad, Waterpody, etc.) d
roposed project to be located and constructed as described
is hereby certified as exempt from the CAMA permit
ement pursuant to 15 NCAC 7K . This exemption
MA permit requirements does not alleviate the necessity of
obtaining other State, Federal or Local authorization.
This certification of exemption from requiring a CAMA pei
valid for 90 days from the date of issuance. Following expii
a re-examination of the project and project site may be nec
to continue this certification.
:TCH (SCALE:

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date
Name of Property Owner Applying for Permit:
ell
iK 132elm -'r
Mailing Address:
.*•
I certify that I have authorized (agent) _ rTI� ,� rC', ,i f� to act on my
behalf, for the purpose ofapplyiag for and obtakdag A CAMA Permits necessary to
install or construct (activity)
at (my property located at)
This certification is valid thru (date) z:
A
31711(a
Property Owner Signature
Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
1 hereby certify that I own property adjacent to ��/ ��e�,6114 : ; � s
(Name of Property Ownerl
property located at
(Address, Lot, Bloc Road, etq.)
an Zet
in F n N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
iocai;o
I have no objection to this proposal_
l 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)
RECEIVE®
DCM WILMINGTON, NC
MAR 1 7 2016
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 wisih 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 Information) (Adjacent Property Owner I ormation)
CA// &'t"
sig 1G r n/S �� ?. sip
Zrjn� T pe N, arse / / Print or Type Nama
MaWina Addressl . - .% ti i A^ Mailinn Address

E7,.. !-mi�
RECEIVED
DCM WILONGTnN, NO
MAR 1 7 2016
/ao
NY
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