Grant

7.►7
CERTIFICATION OF EXEMPTION
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. 010
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Iicant Name �7titb< <,�U C /o 6°66V 1li1�^�. Phone Number 6 ( IU) �I t
ress Vn /k (, a At U )
I tO Wad State Zip
ect Location (County, St a Road, Water Body, etc.) &,4A�A &4 a u o �V-AIA
�r:� Lin _ S� , - _ h—J w �,�
dI I U I I I ICIISIUI IS UI r-1U)CUI
proposed project to be located and constructed as described
,e is hereby certified as exempt from the CAMA permit re-
)ment pursuant to 15 NCAC 7K .0203. This exemption to
IA permit requirements does not alleviate the necessity of
obtaining any other State, Federal, or Local authorization.
This certification of exemption from requiring a CAMA pe
valid for 90 days from the date of issuance. Following expi
a re-examination of the project and project site may be nec,
to continue this certification.
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North Carolina Department -nf c^vtrornment and Natural Resources
N.C. Div+sior of Coastal Management
AGENT AUTHORIZATION FORM
Date �_z �-f--�-
Name of roperty Owner App1png for Permit Name of Authorized Agent for this
Owner's Mailing Address
Email
Pho,rie i
_ Phone
cert.fy that I Have authorized the agent listed above to act on my behalf, for the purpose of ag
for. and obtaining all CAMA Permits necessary to install or construct the folbwrng (activity)
For my property locaned at

4
CERTIFIED MAIL - RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner
Address of Property �� �`-t 0'� �� Z (it/
(Lot or Street 8 Street or rkoac, Gay d County)
Agent's Name 8.& Id /,tS pq MaihngAddress 6
Agent's phone # ��D_ y� 3' 6 1 4!L0a4
I hereby certify that I own property adjacent to the above referenced property. The indivi
applying for this permit has described to me as shown on the attached drawing_the developr
they are proposing. A description or drawino, with dimensions, must be provided with this letl
I have no objections to this proposal. I have objections to this proposal.
H you have objections to what is being proposed, you must notNy the Division of Coastal Afanagement (DC
wrtting within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drtvo
Mnington, NC, 28405-3845. DCM representatives can also be contacted at [phone]. No respor
considered the same as no objection if you have been noted by Certified Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be
back a minimum distance of 15' from my area of riparian access unless waived by me. (If yol
wish to waive the setback, you must initial the appropriate blank below)
NI�sl 1 do wish to waive the 15' setback requirement.
wa-4 I do not wish to waive the 15' setback requirement.
(Property Own �oIPMti )
ctee'v
Signature /
'I,/ -ad <
(Adj ent Prope wner Informati<
ig ature
11 , Z, ( d c �, f'K-

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Mcv�3 25 2017 Joc-6�. C,�rftj
Carve HArns
CERTIFIED MAIL - RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
Name of Property Owner -7
Address of Property
(Lot .?r St. eel a Street or rroac. (,..iiy a lounty)
Agent's Name ;3 t, 'rZ pc� Matting Address 1,L�_�L►_�
Agent's phorieft
I hereby certify that I own property adjacent to the above referenced property. The i ndividc
applying for this permit has described to me as shown on the attached drawing the developew
they are proposing A de$cription or drawing with dimen nt must be l.}ftiylded Watt this Fa3tt
er
I have no objections to this prufx)s:ii. I havc objections to this proposal.
tf you have objections to wnar is 0*ng propvs*d, you must notify the oivrslon of Casstal rWnagamarr {TJCitj
wrfbng wfthln ra days of re'" Pt of this notice. Corraspondenci should be mailed to 127 Cardinal Drive fa
Mrlmington. NC, 28405- M. DCAt represanteov" can also be cantattad at ( lq) 796-7215. No responss
Considered the same as no objection rf you have been nodfiad by C"ned Afail
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse. tift, or groin must be set
bank a minimum distance of 15' from my area of riparian access unless waived by rite, (if you
wish to wai a the setbaej�, you Must initial the appropriate blank below)
_S�aS___ t do Ansh to waive the 15'setback requirement
LJ'f
(1 I do not wish to waive the 15' setback requtcen►enr
L -,o % 61 c r ,
{Propett_y Own 5oprrati j (Adja t Prope wrier inform
0,
Pr
`�Signnrtrrc SiKnrrr
.wnrlrt7l 7� 11ld~ ��G�,+�
YPe rint Type Name 1p
�„���..� f" � ✓ r,� � ..�G.C./, �(1� ts.2 M Q l i i £i �rV A} (�
htetting Address Madinq Address

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