Williams (4)

CERTIFICATION OF EXEMPTION
FROM REQUIRING A CAMA PERMIT nve\r- 071 9 1 7A as authorized by the State of North Carolina,
Department of Environment, Health, and Natural Resources and the Coastal Resources Commission
0 in an area of�envaropmental concern pursuant to 15 NCAC Subchapter 7K .0203.
Applicant Name ,. �/v\L.L� R. v S L k4t�YY►6IVD e+ ) Phone Number �.5 - 326 )--
Address Ic 3C Wu reJW Cr;t-Y- J
City Ch- h G0LIEN rat $4, r State N (._, Zip 2C1/4-1-2-1
Project Loc4tion County,State Roacl, Water Body, etc.) 4 — Ct M - A
0 C v o c.__ i. (,(„ li u t_-.
Type and Dimensions of Project FkUU-+t `'\ (?(It C (eSSC(,i f ,; !-� )( ( (14_4- (ati
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t;L �v►v,v,nUvv, i0. 1r K\ti/ u x - I�tlfw ) UCC -c< CC 2`! XC_
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The proposed project to be located and constructed as described This certification of exemption from requiring a CAMA permit is
above is hereby certified as exempt from the CAMA permit re- valid for 90 days from the date of issuance. Following expiration,
quirement pursuant to 15 NCAC 7K .0203. This exemption to a re-examination of the project and project site may be necessary
CAMA permit requirements does not alleviate the necessity of to continue this certification.
your obtaining any other State, Federal,or Local authorization.
SKETCH (SCALE: h /6„,_ )
PsS 4, ,,,,-, Ill
• qta k
Any person who proceeds with a development without the con-
sent of a CAMA official under the mistaken assumption that the i'Applicant's signature i c--
development is exempted,will be in violation of the CAMA if there 1}
LtAN „. ,_
is a subsequent determination that a permit was required for the sn �'�_�
development. CAMA Official's sgnature Li.
The applicant certifies by signing this exemption that (1)the ap- 7 L i 9 2`
gate i
plicant has read and will abide by the conditions of this exemp- Issuing
tion,and(2)a written statement has been obtained from adjacent I 0/ IQ Jo Z—
e
landowners certifying that they have no objections to the Expiration date
proposed work.
Attachment: 15 North Carolina Administrative Code 7K.0203

DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NO' FICATION/WAIVER FORM.
Name Of Individual Applying For Permit: K.Al M o M C - ► L (\M S
Address Of Property: 1 0 3 0 \A Pk-Ts' (Z_V t„) U 2 1 .
( a2 D L t mik NEW 14 I•J O V L'R,
(Lot or Street#, Street or Road, city & County)
I hereby certify that I own property adjacent to the above-referenced property. The individual
applying for this permit has described tome as shown on the attached drawing the development
they 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 Coastal
Management, 127 North Cardinal Drive, Wilmington, North Carolina, 28405 or call 910 195-
3900 within 10 days of receipt of this notice: No response is considered the same as no objection
if you have been notified by Certified Mail
•
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boat house, lift or sandbags 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.
�OZ Arai
Signs a
1�1. mmilimmow
Pri Nam
�l IrF- a.0 NcDENR
Te ephone Number With Area Code NORTH CAROLINA DEPARTMENT OF •
ENVIRONMENT AND N/ITURAL RESOURCES

DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWANER FORM
Name Of Individual Applying For Permit: K ,1`4 M C L , A r`,
Address Of Property: 103 U W RV (_A) & [Lz
(AN(Lo Lt 4 C_ GA.1 A NJ O V k�
(Lot or Street #, Street or Road,/City & County)
I hereby certify that I own property adjacent to the above-referenced property. The individual
applying for this permit has described toitie as shown on the attached drawing the development
they 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 Coastal
Management, 127 North Cardinal Drive, Wilmington, North Carolina, 28405 or call 910 395-
3900 within 10 days of receipt of this notice- No response is considered the same as no objection
if you have been notified by Certified Mail
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boat house, lift or sandbags 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 mnst initial the appropriate blank below.)
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
Signature ' Date
R013I;R i L- , . 'Jnl xn
Print Name NCDENR
t9 - 45V- 1 ) 3'p
Telephone Number With Area Code NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND N/QURAL RESOURCES

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