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CERTIFICATE OF EXEMPTION
FROM REQUIRING A LAMA PERMIT
as authorized by the State of North Carolina,
Department of Environment and Natural Resources and the Coastal Resources mission
in an area of environmental concern pursuant to 15 NCAC Subchapter
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,e and Dimensions of Project
proposed project to be located and constructed as described
e is hereby certified as exempt from to CAMA permit
rement pursuant to 15 NCAC 7K t�. (; . This exemption
kMA permit requirements does not alleviate the necessity of
obtaining other State, Federal or Local authorization.
This certification of exemption from requiring a CAMA p
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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c1006

NCDENR
North Carolina Department of Environment and
Division of Coastal Management
it McCrory Braxton C. Davis
)ovemor Director
Natural Resources
John E. Skvarla
Secretary
AGENT AUTHORIZATION FORM AGENT AUTHORIZATION FuKM
Date:
ne of Property Owner Applying for Permit:
ner's Mailing Address:
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Name of Authorized Agent for this project:
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Agent's Mailing Address:
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Phone Number nv�5 ) S-TcQ- lwi5--
rtify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
and obtaining all CAMA Permits necessary to install or construct the following (activity):
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my property located at 1 \ A I
certification is valid thru (date'
2
Property O ner Signature Date

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner:
Address of Property:
(Lot or Street Street or Road, City & County)
_
Agent's Name #. � Mailing Address: uo,� &C'A pC�3k(�
Agent's phone#: 1�t, � �dl� � � Gv, �1� 9,)P-(1(N) )\11L Z�LM
I hereby certify that I own property adjacent to the above referenced property. The individual applying for
this permit has described to me as shown on the attached drawing the development they are proposing.
I have no objections to this proposal. I have objections to this proposal.
If you have objections to what is being Vpposed, you must notify the Division of Coastal
Management (DCM) in writing within 10'days of receipt of this notice. Correspondence should be
mailed to 127 Cardinal Drive Ext., Wilmington, NC, 28405-3845. DCM representatives can also be
contacted at [phone]. No response Is considered dw same as no objection if you have been
notified by Certified Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, 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.)
IµJ' #,rlieli,J
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
br�, �, (-Ck*2�o
Signature�
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Print or Typ6 Name
Mailing Address
City/Sta ip
j ro er y O tion)
Sign e
M ;cka-el
Print or Type Name
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Mailing Address
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Cy/State/Zip

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For delivery Sinformation visit our website at www.usps.come
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Postage $ $0.49 0459
Certified Fee $3.30 01
Return Receipt Fee Postmark
=ndorsement Required) $2.70 Here
Restricted Delivery Fee
-ndorsement Required) Sri . 00
Total Postage & Fees 1 $ $6.49 I 09/16/2014
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G.�. J' 1Y( 2-k-q(.4y
300, August 200E
0.1 UtH I 11-1LU MAIL,,., RECEIF
(Domestic Mail Only, No Insurance Coveral
For delivery information visit our wah-q1tp At —
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M Postage $
c:] Certified Fee
C:1 Return Receipt Fee Postmark
(Endorsement Required) Q. 70 Here
Restricted Delivery Fee
El (Endorsement Required) $0.00
Total Postage & Fees $ $6.49 09/16/2014
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PS Form 3800, August 2006 See Reverse for lnstructio�
Maits
MHCDO
Tyler Crumbley
LPO
DW Review
Scan to DMoye

■ Complete items 1, 2, and 3. Also complete
item 4 if Restricted Delivery is desired.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
1. Article Addressed to:
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2. Article Number
(Transfer from service label)
Signature
C.
❑ Agent
n Addressee
D. Is deliv¢,ry address different from item 1? U Yes
If YES, enter delivery address below: ❑ No
3. Service Type
��ertified Mail ❑ Express Mail
❑ Registered _JiEhieturn Receipt for Merchandise
❑ Insured Mail ❑ C.O.D.
4. Restricted Delivery? (Extra Fee) ❑ Yes
PS Form 3811, February 2004 Domestic Return Receipt
1.02595-02-M-1540
■ Complete items 1, 2, and 3. Also complete
A. Si e
item 4 if Restricted Delivery is desired.
■ Print your name and address on the reverse
❑Agent
X—❑ Addressee
so that we can return the card to you.
■
B. v (Print -
"
Attach this card to the back of the mailpiece,
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elivery
or on the front if space permits.
1. Article Addressed to:
D. Is deli ery aiA dit f�b jt*r1 1? Yes
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If YES enter delivery address below: _
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3. Service Type
ZlKili;ertified Mail ❑ Express Mail
❑ Registered .Return Receipt for Merchandise
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❑ Insured Mail ❑ C.O.D.
4. Restricted Delivery? (Extra Fee) ❑ Yes
3407 0505
2. Article Number
(Transfer from service /at 7 013 1710 0000
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