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CERTIFICATE OF EXEMPTIONO �"
FROM REQUIRING A LAMA PERMIT 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 7KQjL0 L
licant Name } 0"0i� �' � I ��-J� — `]�n I f� n✓ Phone Number
ress
" 1 �2 L AL o State NC, Zip
ject Location (County, State Road, Water Body, etc.)
e and Dimensions of Project VLL
proposed project to be located and constructed as described
e is hereby certified as exempt from the CAMA permit
irement pursuant to 15 NCAC 7K �1 rA . This exemption
MA permit requirements does not alleviate the necessity of
r obtaining other State, Federal or Local authorization.
This certification of exemption from requiring a CAMA
valid for 90 days from the date of issuance. Following e,
a re-examination of the project and project site may be i
to continue this certification.
KETCH (SCALE: I � /
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N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date
Name of Property Owner Applying for Permit:
Mailing Address:
I certify that I have authorized (agent)
to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity) �5ea 041 Yr-I1 0'
at (my property located at) �✓`t/ oC 54
This certification is valid thru (date) �30��
404
Date

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CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner: ;541A Of OoI�G ISI,
Address of Property: ��U d✓l St- �2'2
(Lot or Street #, Street or Road, City & County)
Agent's Name #: / 111 Cl1/f l P
Agent's phone #:
Mailing Address:
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. A description or drawing, with dimensions, must be provided with this letter. c\
I have 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
(DCM) in writing within 10 days of receipt of this notice. Contact information for DCM offices is
available at Nrww.nccoas<l agement.net/contact dcm.htm or by calling 1-888-4RCOAST. No
response is considered the 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.)
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
Signature
(Adjacent Property Owner Information)
Signature
Print or Type Name
Print or Type Name