McMurray

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.
cant Name/7ufC �% t�/,r % t�Qf�� ✓° Phone Number 'A
ass �' ,� � ' 0 7,�r
i // P State %V C ZiP 7 P'
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act Location (County, State Roa ,` Water Body, etc.) 1 / D EUer L ;� S� d . - �U
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w _ n / { 1 1 � it wi, s L C
and Dimensions of Project j iiiy 1s�� «` P� e TN C44'll
,roposed project to be located and constructed as described
is hereby certified as exempt from the CAMA permit re-
ment pursuant to 15 NCAC 7K .0203. This exemption to
A permit requirements does not alleviate the necessity of
obtaining any other State, Federal, or Local authorization.
This certification of exemption from requiring a CAMA per
valid for 90 days from the date of issuance. Following expir
a re-examination of the project and project site may be nece
to continue this certification.
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North Carolina Department of Environment and Natural Resources
Division of Coastal Management Dee Freem;
Beverly Eaves Perdue James H. Gregson Secretz
Governor Director
AGENT AUTHORIZATION FORM
Date:
=:7a,,e
,r Applying forermof Authorized Agent for this project:
C
Owner's Mailing ddress:
Phone Number F-M
phone Num
I certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
for an4 obtaining all CAMA Permits necessary to install or construct t� following (activity): Di o
(my property located) at
This certification is valid thru (date) a
4
Pronertv Owner Signatur Date

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CERTIFIED MAIL -- RETUWN. RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to o7ruC e r e 's
(dame of Property Vner)
property located at �� �e r o
(Lo locl ,Road .)
on l /4/iQ `.�. , in N.C.
(Waterbody) (Town and/or County)�/
Applicant's phone #: % �(o - 40?� - D� Mailing Address: �U.� ,9kA'V 31i 11V 6.
!' P Al. G A 9 S
FIe/She has described to me as shown below the development he/sh is proposing A that location,
and I have no objections to the proposal.
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DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(Individual proposing development must fill in description below or attach a site drawing)
Leivff
An Vf
If you have objections to what is being proposed, you must notify the Division of Coastal Nlanagement (DCM) in witin
r
within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive Ext. Wilmington, NC
DCM representatives can also be contacted at [phone]_
No response is considered the same as no ob•e tion if you have been notified by Certified Mail
(Prop ty Owner ;Ipfrmaf n) "� ' "` (Riparian Property�vner Information)
VI)• c(c,
Sign ture
�ru ce%
Print or Type Name
Majling Addre s
� ./ - ,.1 V1 A;
Signature
Print or Type N e
Mailing Address
10 it- _, '// nl /i 417„

b"#Ve"-
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to _
(:Name of Property Owner)
property located at 116 1 iix �� - '
(Lot, Block, Road, etc.)
`� n , N.C.
on &� A-! � , in
(Waterbody) (Town and/or County)
hh r ??,,,,
Applicant's phone #:a��� �o��- �/%�Ilailing Address:�fa a�!
He has described to me, as shown below, the development he is proposing at that location, and, I
have no objections to his proposal.
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DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
{To be filled in by property owner proposing development)
(Information for Property Owner Applying (Riparian Property Owner Information)
for Permit)
20 01 An ' G
Mailing Address 1 Signature