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�licant
ject Location
CERTIFICATE OF EXEMPTION ,?2:t`
FROM REQUIRING A CAMA PERMIT
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as authorized by the State of North Carolina,
Department of Environment and Natural Resources and the Coastal Resources Commission
in an area of environmental concern pursuant to 15 NCAC Subchapter 7K_��. I )b , 51z .SA
`AYNnjo,' JV&AVAUAA Phone Number e Z-.
e and Dimensions of Project
)roposed project to be located and constructed as described
is hereby certified as exempt from the CAMA permit
rement pursuant to 15 NCAC 7K ,fl c'. This exemption
kMA permit requirements does not alleviate the necessity of
obtaining other State, Federal or Local authorization.
FA,
This certification of exemption from requiring a CAMA pi
valid for 90 days from the date of issuance. Following exp
a re-examination of the project and project site may be ne
to continue this certification.
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Applicant
CERTIFICATE OF EXEMPTION
FROM REQUIRING A LAMA PERMIT
N° 01
as authorized by the State of North Carolina,
Department of Environment and Natural Resources and the Coastal Resources Commission
In an area of environmental concern pursuant to 15 NCAC Subchapter 7K �j_�,
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Phone Number'-1`�o Z
City .. _ ' Y_QC ___r _..__ -etc
_-.-- _—. ,Stale _>�— — _ - Zi—p
Project t_ocation (County, State Road, Water Body, etc.}Y1fk15k�tlta
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Type and Dimensions of Project
e proposed project to be located and constructed as described
ave is hereby certified as exempt from the LAMA pen -nit
luirement pursuant to IS NCAC 7K _ LCft,_), This exemption
CAMA permit requirements does not alleviate the necessity of
.►r obtaining other State, Federal or Local authorization.
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This certification of exemption from requiring a LAMA p
valid for 90 days from the date of Issuance. Following exf
a re-exanV ai aTi on of the project and project site may be n►
to continue this certlOcatlon.
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I V E D
IAVa" WILMINGTON, N�
MAR 2 0 2014
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North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue James H. Gregson
Governor Director
Dee Fre
Sec -
AGENT AUTHORIZATION FORM
Date. I-2S- ly
Name of Property Owner Applying for Permit. Name of Authorized Agent for this project-
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Owner's Mailing Address:
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Phone Number
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Agent's Mailing Address:
18y3 �1 �T�t t L A v E ___--
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Phone Number (I ra ) St Z - 5�35
I certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
for and obtaining all LAMA Permits necessary to install or construct the following (activity):
L--gft kg C Lo q T7,.�Gr tcw .
(my. Property. at rARi- t-I ORiy E i-f oc,� f.� ��1 G�Cde-
This certificabon is valid thru (date)
!•2S-ry
Property Owner Wenature Date

s A{a.: /
CERTIFIED MAIL - RET�RECEIPT REQUESTED
DIVISION OF COASTAL MA- IAGEWNT
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to
s
property located at %� /i'/ //n! �/�ld� of Prop rty Owner)
on
(Lot, B o d etc.
N.C_
in '
(Waterbody) (Town and/or County)
Applicant's phone #:- ��- /C� Mailing Address: /02 CTD /j'Ji
—Ci7Q•✓.eo e G -1
He/She has described to me as shown below the development he/she u proposing at at lemon,
and I have no objections to the proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
{Individual proposing development must fdl in description below or attach a site drawing]
If you have objections to wbat is being proposed, you must notify the Division of Coastal Management (DCM) in writ
within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive Ext. Wilraington, NC
DCM mpresentatives can also be contacted at [phone].
r! J = use ;S cu uiuered the same as ►to ob'ection if you have been notified bv Certified Mail
(Propert) }w er Information)
Signature ./ l/
Print or Type�za
Mailing Address- - A—lev 4112 oe— /1/-2!
-'
(Riparian Property Owner Information" )
1-a�Iee ,r
Print or Type Name
Mailing Address

CERTIFIED MAIL — RETURN RECEIPT REQUESTED
DMSION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER STATE IE�t-T
Name of Property Owner:
Address of Property: —//
(Lot or
Applicant's phone #:106M 1p/ y
- �_
rree0#1 Street or Road, City 8t County)
Mailing Address:
/"%%D�t//1 Pe f A/ 4 ' XIIC
I hereby certify that I own property adjacent to the above referenced property. The individual applying for this pe
has described to me as shown on the attached drawing the development they are proposing. A description of draK
with dimensio must be provided with this letter.
�T- ve no objections to this proposal. I have objections to this proposal.
If you have objections to what is being proposed, you must notify the Division of Coastal Management (DC
in writing within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive.
Wilmington, NC 28405-3845. DCM representatives can also be contacted at [phone]. No response v
considered the.same as no objection if you have been notified -by. Certified Mail.
WAIVER SECTION
1 understand that a pier, dock, mooring pilings, breakwater, boathouse, or Iifft must be set back a minimum distant
15' &om. 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 IS' set back requirement.
I do got wish to waive the IS' set back requirement.
(Proper Owner I formation)
Signature
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Print or Type N e
(Riparian Property Owner Information)
Si
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Print or Type Name
Mailing AddressZ?(,� m,
Mailing Address
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