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CERTIFICATION OF EXEMPTION
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.
t
Applicant Name OAVt(1e- TV,Cl t--!"' Phone Number 3^j(o 7(�nO"O3'26
Address BUS W►rOht.cr Cuv_rt
City State 1‘1C') Zip _s7 1!
Project Location(County, State Road,, Water Body, etc.) - r (\St-J.1 c K— C nu...r\4.1 t 1'J
te\',1 ��h .c;1 r♦r ,, M fm Mflic _J O A l l
Type and Dimensions of Project A.nri c'10 4 -', h ch t--
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: kc, !v
C,/of, 1
f IUAT
10
50' W,do L r
e�-
Any person who proceeds with a development without the con- /�
sent of a CAMA official under the mistaken assumption that the -Apr Signa
development is exempted,will be in violation of the CAMA if there
is a subsequent determination that a permit was required for the
development. CAM fficial's signature
The applicant certifies by signing this exemption that (1)the ap- 1 t �U
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 '."�'�`} t)(}
landowners certifying that they have no objections to the Expiration date � '
proposed work.
Attachment: 15 North Carolina Administrative Code 7K.0203

SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY
■ Complete items 1,2,and 3.Also complete A. Received by(Please Print Clearly) B. Dat• if Deliver}
item 4 if Restricted Delivery is desired. _ v d , , ‘, k -
■ Print your name and address on the reverse
so that we can return the card to you. C. Sig - re
• Attach tIL3 card to the back of the mailpiece, 0 Agent
X ci 4.-yG///J‘Cs. 0 Addressee
or on the front if space permits.
D. Is delivery address different from item 1? 0 Yes
1. Article Addressed to:
If YES,enter delivery address below: 0 No
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t7I (3 beEhtu &vt. wEsT
1JIJEN 13E 1i, N .207pJ)
42- 3. Se ice Type
fied Mail 0 Express Mail
Registered 0 Return Receipt for Merchandise
❑ Insured Mail 0 C.O.D.
p 4. Restricted Delivery?(Extra Fee) 0 Yes
2. Article Number o y/rom service abel)� ^ Q •f A 1�
h4[hY`n ���J !mil,'Gl
PS Form 3811,July 1999 Domestic Return Receipt 102595-00-M-0952

UNITED STATES POSTAL SERV Fr.:d(L1-F 1 11 11 First-Gfass-AAail
,., p M ? c _ _ Postage-&�e�s Paid
• Sender: Please print e, address,and ZIP 4-trrThis box
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APR-24-01 07:56 From:RJRT AMA & VISA SALES EXE 336T416677 T-457 P.02/02 Jab-954
sS'
• .4,; a.
:::
Of Individual Applying Tam
G! Pt-opatrty:
(Lot or brass ream or o $ ty aun y)
X hereby certify •that I own property ed f ecent to the above-,
referenced propertg. The individual, applying for this p4111$t
described to ma as shod on the attached drawing the development
they are proposing. A description or drewingi •v:th dim®upioni,
should be -rovidsd with tI:iv better.
,• = hays no objections to this 'proposal..
-T v - -i4P - . seats3e ���Lp thhs
mairsor
ManaLJULEIM
I understand that a pie;:, dock, mooring pilings, braeakwatasr, boat
!souse, loiet or sandbags must be set back a•minimum distance of U'
from myr•aree of riparian access unless waived by me. at you wish
to waive ram setbeeK, you =az initial the appropriate blank
below.)
do wish to waive the IS'setback regaire , nt-
I wish to weivs the Ttbk
requirement.
Vitasnormaillk
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FICalr
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DIVISION OF CO4STAI, MAN4GEMENT
• AD.IACENrT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name Of Individual Applying For Permit: l� Ce
Address Of Property: /20 56t %f ,z9
I
(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 tone 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, 177 North Cardinal Drive, Wilmington North Carolina, 78405 or call 910 '395-
'3900 within 10 days of receipt of this notice No response is considered the same as ao objection
if you have been notified by Certified Mail
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boat house, lift aisaimoliongs 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.
lido not wish to waive the 15' setback requirement.
ZjA
•
Signature •
Date
Print Name
NCDENR
Tel
ephone Number With Area Code NORTH GAROUNA DO.ARTI ENT OF
ENVIRONMENT AND NATURAL RESOURCES