02203D - Rahmani

CERTIFICATE OF EXEMPTION
FROM REQUIRING A LAMA PERMIT /(� a
as authorized by the State of North Carolina, 6
Department of Environment and Natural Resources and the Coastal Resources Commission
in an area of environmental concern pursuant to 15 NCAC Subchapter 7K . / 9 1�)�o ( ^,3,
r0I H . Ka h WiA i . c%o rA (ACWa4f✓ N1 u r,,u ( *,A4 Phone Number ' I -C4,
-pe and uimensions of P
proposed project to be located and constructed as described
,ve is hereby certified as exempt from the CAMA permit
uirement pursuant to 15 NCAC 7K I (' 2 . This exemption
:AMA 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.
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4/2013 15:15 FAX
16003
North Carolina Department of E,rlvironcent and Natural Reseurces
- Division of Coastal-Niariagement
Beverly Eaves Perdue James H. G*wn
governor arecior
AGENT AUTHGRt7�+TIQ FN QRM
Date: L
ame of Property owner Applying for Permit:
a ✓8 /�
wners Mailing Address'.
��
u itt77
)hone .Number ( 9f �l
Dee Freeman
Secretary
Name of Authorized
ff Agent for this project:
Agents Mailing Address_
t
Phone Number
certify that I have authorised the agent listed above to act on my behalf, for the purpose of applying
'or and obtaining al CAMA Permits necessary to install or construct the following (activity):
(my property located) at
This certWicaiiort is valid thru (date) _, ` eZG -
Property owner Signature pate

4/2013 15:15 FAX 0004
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOXY A plvR/hfWI 2'.NG PIL[N'GSIBOA7UPT/BOATHOUSir')
1 hereby certify that I own property adjacent to �� ✓z� 'S
(Name of Property Owner)
property located at G r�is/w 4�lrt�'
(Lot, Block, Road, etc.)
on , in .0 , N.C.
aterbody) (Town and/or County)
#: 91g"MailingAddress: f �vv�,�v IJr'ui^r I
Applicant s phone
He has described to me, as shown below, the development he is proposing at that location, and, I
have no objections to his proposal. I understand that a pier/mooring pilings / boadift / boathouse
must be set back a ininimium distance of fifteen feet (IS,) 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 not wish to waive
I, do wish to waive that setback requirement.
DESCPJP`I`ION AND/bR DAAWIN6"OF PROPOSE>b iSE�,OPNCI NT_
(To be ftlled in by Individual proposing development)
IK�.(Q ►�`�tcrt�l
------------ eA ------
- ---------------- — - --------- 7-6 ---------- ------ ?4 --
(Information for Property Owner Applrying (Riparian Property Owner Information)
for Permit)
vn��Nc
Mailing Address
citylstZe/
919- 9-0 / - gr�
ignaturc
�^ Print or Tyoe Name

1/2013 15:15 FAX
Z 005
ADJACENT RIPARIAN PROPERTY OWNER ST4kTEMMT
(FOR A PXER4iOO)UNC BTUNGSIBOATUFT/BOAT.TOUSE)
1 hereby certify that I own properly adjacent to ea'vol A�
a+�!-w 1 's
(Name of Property Owner) -
ro erty located at
(Lot, Block, Road, etc.)
on
_ in N.C.
�('Waterbody) (Town and/or County)
Applicant's phone #:_...( Meiling Address. ' r,� S 1-�✓�
He has described to me, shown berow, i} development he is proposing at that location, and, I
have no objecticros to his prapOssl. I understand that a pierlinooring pilings / boatlift / boathouse
must be set back a minimum distance of fifteen Feet (15') from Tny area of riparian access unless
waived by me. (If you wish to waive the setback, you must initial the appropriate blank
below.)
I dQ not wish to waive
—_— 142wish to waive that setback requirement
---- ------------- -----l-__-^------
�`__._»..---_--..- »____. _
--•�-----__------- ------ ---------
DESCRW110N AND DRA:WINO OF PitOPOSFD DEVk)LOPMIkNT:
(To be fined in by individual proposing developmerrl)
- - ------- - ------------------------------- - - - (
(Xnfor ation for Property Owner Applying (Riparian Property Owner Wormatiou)
for Permit)
u,vNM,(
Signature
Mailing
%Address
r
Print or Type Name
City/Stet ,ip
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