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x CERTIFICATION OF EXEMPTION ��.
FROM REQUIRING A CAMA PERMIT P 0(0 .2114
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.
Applicant Name ...I't
+ to 'IA-f\,P Phone Number , LG .f:: cy' I '15
Address y21 Mc.>E1dn Li)L)od --h r ,Jc_.
City LBurl',r, - 4 „ - State 1\J ) Zip Q1Q 1.5"
Project Location(County, State Road, Water Body, etc.) �jrkansw:c1._ C/o v,(vi 1 Co 1 .5fr�di �, pe-,r'
"t),,, , Tsl: $ -In . U1rl 5a�r.d X--F.LI
f Islf�nCe PAr K-) ►-Q-r 1-- -1
Type and Dimensions of Project j\1C 1 Q\ar tad fc 1uf0 (1c` aoct . C)(A04 ye--, '
ej',1 t f, !%'A'}'
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: Nor (V )
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Any person who proceeds with a development without the con- f 1( r t t �,C,,, \jj .,c, ..„
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 / ��
is a subsequent determination that a permit was required for the ]L
development. CAMA'�Official's signature
The applicant certifies by signing this exemption that (1)the ap- 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 e- a? , UO I
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:
•
Address Of Property: e
• (c) t 9 c- -- e874/(0
_
•-• (Lot or Street Street- or Road, City -& County) -
:•:.property' .adj a c ent
rffitez*ic.pck-Aorcppotty.-:::,i , he individual applying for this perittit has
describedpto me as shown on the attached, drawing t thedevelopment
-„they:::arey:proposirig.c::: ?,:!.k.f.i)despription': or drawing, with
should ,Pe provided: with. this- letter-. - _ , :
N./
have objections to - : - •
If you-have objectionsto lahat7:isbeincr•p-ropose
Division Of Coastal ,Management.i 127 Cardinal . -Drive, - Extension
Wilmingtbn",, North ,Carolina 28405 or, call -'9:10 395:. .39'.0.0:
10
_ .
days of receipt.: of this notice NO response !.i.s:-,‘conSidered-..the
as no objection you have been' notified
- WAIVER SECTION
ing
= - house, be set back. a '.minimum distance of 15'
from, my..,:lareaii_of.....:riparlan:, QCse :Unless waive&fby,::me.',:;`,-(If you wish
waiveto initial.- the appropriate--_• ?..';:b
below. . , , -
• I do wish to waive the 15/setback requirgInent.
- • •- -do-nbt wish:to Wa±Vé the1-5.1-'setback,. re,guirertent..;,'.1
o Tir* •
•
Sq...gnature ate q •
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Print Name • mimmimmmft
• c cnci - EDE I—I F=I
Telephone Number With Area Code
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