Bird

CERTIFICATION OF EXEMPTION
-Thr) 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.
licant Name 5;5Qde h je,4 S YO A4,N•e 17--1 Md/Z Phone Number CGS`' S 7ti
ress /2.2/ .5,,J , l GyA,c4 /744ce
ayNc A14N,Y gg State j//q- Zip 2
ject Location(County, State Road, Water Body, etc.) /21 /'2l�,c L,", -k,, . , A d•Ae,.�'1 ,v /V 09�
AA o C /�. ,42/!-,,/'✓, //aIc/.•.-. /i' cA, ditN,.Jw,ct (1/H �/7-
)e and Dim/e^nsio s of Project /� gc e /G �stc 71, .� of E�x► c �y Z '6 6) al i�
•in Y' O[? 12,,-. / * fa le -Iia �. Qr444►ct'd.
proposed project to be located and constructed as described This certification of exemption from requiring a CAMA F
ve is hereby certified as exempt from the CAMA permit re- valid for 90 days from the date of issuance. Following exi
'ement pursuant to 15 NCAC 7K .0203. This exemption to a re-examination of the project and project site may be ne
VIA permit requirements does not alleviate the necessity of to continue this certification.
r obtaining any other State, Federal, or Local authorization.
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27-2007 19:00 From: To:91N8,427r4b P.c
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Individual Applying For Permit: J ds
Address of Property:__12 Y'{ tr 1 ( h �D r'IV e_
(Lot or Street#, Street or Road)
'kid. ?)icaein
(City and County)
I hereby certify that I own property adjacent to the above-referenced property. The individua
applying for this permit has described to me as shown on the artached drawing the development the
are proposing. A description or drawing, with dimensions, should be provided with this letter,
I have no objections to this proposal.
If you have objections to what is being proposed, please write the Division of Coasta
Management, 127 Cardinal Drive Extension, Wilmington, NC 28405 or call 91.0-796-721:
within 10 days of receipt of this notice. No response is considered the same as no objection i
you have been notified by Certified Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boat house or boat lift must be se
bck a minimum distance of 15' from my area of riparian access- unless waived by me. (Ifyot
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.
Si.
ame Date
Ph I e- .S#/e S
Print Name Aim
r/�
NCDEN
R Number with Area Code ____�_ NA

•
SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY
• Complete items 1,2,and 3.Also complete A. Sidf
item 4 if Restricted Delivery is desired. X `/ 0 Agent
• Print your name and address on the reverse A�,0._ B Addressee
so that we can return the card to you. B. Received by Vrinted Name) C. Date o Delivery
• Attach this card to the back of the mailpiece, T.A.F. n'
or on the front if space permits. (/Z./N - 1- 7.
1. Article Addressed to: D. Is delivery address different from item 1? 0 Yes
If YES,enter delivery address below: 0 No
Ts� h bird
� � L ck nacL-
Li rich Jul c� a h J�,y//h
buy(( "a , 3. Service Type
Z 4 J a eegrtified Mail 0 Express Mail
R istered 0 Return Receipt for Merchandise
❑ Insured Mail 0 C.O.D.
4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number
(Transfer from service/abe 7005 0390 0003 5186 9077
PS Form 3811, February 2004 Domestic Return Receipt 102595-02-M-1W