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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.
flicant Name BJZ'C K L-'9"b s - A?C A's Phone Number
Iress / 'IL R,�� /9� ,.., Rd
State /'v Zip 27
ject Location (County, State Road, Water Body, etc.) / 72 /a
e and Dimensions of Project Pl"it?
proposed project to be located and constructed as described
✓e is hereby certified as exempt from the CAMA permit re-
gment pursuant to 15 NCAC 7K .0203. This exemption to
AA 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 exp
a re-examination of the project and project site may be nec
to continue this certification.
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ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSBOATLIFTBOA77IOUSE)
I hereby certify that I own property adjacent to ,�,�/c �D� GL-e—' 's
(Name of Property Owner)
property located at 1 ? - —
(Lot, Block, Road, etc.)
on I C: c--) , in � 1�4 /1rs77-C , N.C.
(Waterbody) (Town and/or County)
Applicant's phone#: 9/0-36'7-4957Mailing Address: C-Xcu Cz-epk C
013 ,c,C
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 / boatlift / boathouse
must be set back a minimum distance of fifteen feet (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 not wish to waive
I do wish to waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
(Information for Property Owner Applying
for Permit)
Mailing Address
54N/lom- ems.
(Riparian Property Owner Information)
2 Power
Signature

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PIUNGS/BOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to 3 t�C . -�,7i -, 1 LL is
(Name of Prope ty Owner)
property located at 13 Z(ek L �l
(Lot, Block, Road, etc
.)
G l
on 1 c-> , in 5 A,4 /(dfiz- , N.C.
(Waterbody) (Town and/or County)
Applicant's phone #: 9/O-�3C7-G95-Z-Mailing Address: /59.5- cxcvOit /C4wt- GI
6123 /x . 7,644ct
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 / boatlift / boathouse
must be set back a minimum distance of fifteen feet (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 not wish to waive
/ --- — ----------------- - ----------- - --------------- - ---------------------------- - -- - -- - ------
do wish to waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be f &d in by individual proposing development)
(Information for Property Owner Applying
for Permit)
Mailing Address
(Riparian Property Owner Information)
-&:, Z""/�
Signature
J W r4 TSC�iL%

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�
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue, Govemor James H. Gregson, Director Dee Freeman, Secretary
Date ► - Z G — It
Name of Property Owner Applying for Permit:
Mailing Address:
/ 7 Z
ski.,- &0-7-C'
I certify that I have authorized (agent) (A-�reS7 peel S / Sb�-.t,J��/ to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity) Sew wall F=ePf9-►fZ- ,
at (my property located at) /P*&^ Dn44
This certification is valid thru (date) L/ --/%
Property Owner Signature
Date

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