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CERTIFICATION OF EXEMPTION
FROM REQUIRING A CAMA PERMIT
as authorized by the State of North Carolina,
Department of Environmental Quality and the Coastal Resources Commission in an area of
environmental concern pursuant to 15 NCAC Subchapter 7K <'1,- `'or NCGS 113A-103(5)(b)(5)
Applicant Name I�I.(IEPrbpexki //cid/01 c L6C °1'" 57�� Phone Number 678 --778' *15
Address L/ 70 q` _ Nafac PetVk 9-ri • ;
City C.(n ow'k 1-k State C- Zip gS Z 7I2
Project Location(County,State Road,Water Body,etc.)
. _.ILA J Q J c� nave
(kt r Icf ou.-d Z.5, YLo c f-1-trok,{ CQcc-or
Type and Dimensions of Project TeJ�}� u►�e_ �i ova `�
Cc \Lf Co or l es S. <;GI e-
The proposed project to be located and constructed as This certification of exemption from requiring a CAMA permit
described above is hereby certified as exempt from the is valid for 120 days from the date of issuance.Following
CAMA permit requirements.This exemption to CAMA expiration, a re-examination of the project and project site may
permit requirements does not alleviate the necessity of be necessary to continue this certification.
your obtaining any other State, Federal,or Local
authorization. Aye} • L1 Co L, P1G(con....,
I L./t/2-020 No dut1, .prc.Serk
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Any person who proceeds with a development without the con- X ..-----'e,e Alvk
sent of a CAMA official under mistaken assumption that the Applic is signat
development is exempted, will be in violation of the CAMA if there ?�r�,Cl�.�
is a subsequent determination that a permit was required for the
development. CAMA Official's signature The applicant certifies by signing this exemption that the 1 Z/Z/Zbl }o t/g hn L.j
applicant will abide by the conditions of this exemption. Issuing date Expiration Date

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AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: 3£3/►A Sri 6.h $ fe h,G.r
Mailing Address: L/7�r1 / OT A 5 /2J4 rd.
CA c4- lG ik , Ai 6, 2,202
Phone Number: [t 7g 776 -
Email Address: J b 5 I a l et 7 `{ 5 mei. !, Lorn
I certify that I have authorized L, /15C/1 /3i t i-c "-t
Agent/Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMAA permits
necessary for the following proposed development: /'/it' 11 ,3/3hb' Pas 4
/ fDfJ (77
7
at my property located at ��O S We3 t & A Q r, C P K 1��"u
in 13ra h.5 to.Git County.
I furthermore certify that I am authorized to grant, and do in fact grant permission to
Division of Coastal Management staff, the Local Permit Officer and their agents to enter
on the aforementioned lands in connection with evaluating information related to this
permit application.
Property Owner Information:
td4q, S AJ c_,,
Signature
Jo h, 7 t�Lt) Q,f
Print or Type Name
Q l /tEk
Title
l/ 130 I ,20,20
Date
This certification is valid through I /
1

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ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to T l '4 K 's
31 (Name of Property Owne )
property located at A( I j, c `, / .t 1r 114
(Address, Lot, Block, Road,etc.)
on ALA l�� c `� ran , in A K '� 11 , N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location.
I have no objection to this proposal.
I have objections to this proposal.
`- DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
-4 S Gc pl,LS A Q+ J1 Gl1J a C n l'�p t''
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, 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 Infot than) (Adjacent Property Owner Information)
r ,, `ice, ,j �-1�
Signalurg, h Signature*
0.,4 1- JJ(i_r j
Print or pe Na ) Print o Type Name
�> r, E,i t. ti ( 4 ... ) �,i,; ,
Mailing 90dress Mailing Add ss
/ J5-79 (1,1,
City/StaW/Zip C, 1 Alt c)17/3 City/Stale/Zip
I5V s a,• Tc.t /�C -/)5;
emailTelephoneumber/ i address Telephone Number/email address
Sag 5O7 107 //-30-�0:
Date I 1_ - a Q Date'
(Revised Aug. 2014)