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CERTIFICATION OF EXEMPTION
FROM REQUIRING A CAMA PERMIT p 0 3U5- 20 f"
as authorized by the State of North Carolina,
0 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.
Applicant Name T) t M s 9 d�tC-- I Phone Number 1-4 U i 76 U7O. .
Address 11 L4 P)r Ut4ir SiNe t"
City 1) r a U, rt c ' State I Zip Q2cj UCr
Project Location(County,State Road Water Body,etc.) 1!j r+A r\ vJ, ( C'v w?4 14U"- 1"i
i.r '_.c= i ' tk n Z .--n r G, ''(\Pi,?..- V\n d ci C',A-r‘f1 1
Type and Dimensions of Project c inc c ft f\1. �q an L_ ; C n UJ C Una Sr cc
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: NUT T )
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Any person who proceeds with a development without the con-
sent of a CAMA official under the mistaken assumption that the Applicant's signature
development is exempted,will be in violation of the CAMA if there j
is a subsequent determination that a permit was required for the - ��
development. CAMA Official's signature
The applicant certifies by signing this exemption that (1)the ap- (�. , f W�
Issuing date
plicant has read and will abide by the conditions of this exemp-
tion,and(2)a written statement has been obtained from adjacent ---\f _.,.,¢ C.
, eA UUa
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 NOTIFICATION/WAIVER FORM
�� �� ��
Name of Individual Applying For Permit: __��r����_�J� _..............
Address of Property: _K.AO�'_ --.____________________
--------------Z------ ----------------
(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 to me as shown on the attached drawing the development they
are proposing . A description or drawing , with dimensions, should be .
popvided with this letter.
./
............................... �_ I have n9 objectives to thds proposal .
If you haveobjqctions� to what' in being proposed, please write the
Division of Coastal Management, 127 Cardinal Drive Extension,
Wilmington, NC 28405 or call 910 395 3900 within 10 days of receipt of
this notice. - No nesponse-is'zonsidered the same -as no-objaction if
ycu have been notified -by-certified mail . '
................................_....._..............................._..... ........... ..................................... .................................. .................... ...__________________________
____________________________________________________________
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boat
house, lift or sandbags must be sat 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.
................... .......... ...................... ........................ ..... ....................................................___.....�......................................................_....................................................
________
.................... ' '� .........�.....�....... .........
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Sign a t u
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Print Name
x� � � ��
______����_��-��_-1-����___________________ '
Telephone Number with Area Code

ENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY
■ Complete items 1, 2, and 3.Also complete A. Received by(Pease Print Clearly) B. Date of Delivery
item 4 if Restricted Delivery is desired. 3 U,i& e h se h
■ Print your name and address on the reverse
so that we can return the card to you. C. Signature
• Attach this card to the back of the mailpiece, X \ ❑Agent
or on the front if space permits. Z�t,, ❑Addressee
D. Is i - df15 t from item 1? ❑Yes
t. Article Addressed to: If ES nt cliOr addriiss below: 0 No
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U•N.e.\ -b ec c'r i N(- 3. Service Types
.-Certified Mail —❑)Express Mail
2cq�g 0 Registered L "Return Receipt for Merchandise
0 Insured Mail 0 C.O.D.
4. Restricted Delivery?(Extra Fee) 0 Yes
?. Article Number(Copy from servi . .
7001 0320 0005 9189 6524
'S Form 3811,July 1999 Domestic Return Receipt 102595-00-M-0952

UNITED STATES POSTAL SERVICE First-Class'Mail '
Postage&Fees Paid
USPS
Permit No. G-10
• Sender: Please print your name, address, and ZIP+4 in this box •
GRICE CONSTRUCTION
6618 BEACH DR. SW
OCEAN ISLE BEACH NC 28469
[phone] •
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PM c� P Permit s1.1ro-
• Sender: Please prinky ram , address, and ZIP+4tw-this box' -
GRICE CONSTRUCTION
6618 BEACH DR. SW
OCEAN ISLE BEACH NC 28469
[phone]

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