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CERTIFICATION OF EXEMPTION
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FROM REQUIRING A CAMA PERMIT P vejOZ fl
as authorized by the State of North Carolina, --
Department of Environment, Health, and Natural Resources and the Coastal Resources Commission
inin tan area of environmental concern pursuant to 15 NCAC Subchapter 7K .0203.
Applicant Name 1 uti) rl o f Cr -y - \ T 5 t( - Phone Number 6 1 9 - 3 LI -1
Address 3 Ude ST 3t J'tY'f',(-'t'
City r1 (: -,- t; . n,- !,. State i ZiP
Project Location(County, State Road, Water Body, etc.) ),ri.) r S Lk. ,C I.- o utM
• 5 Ctausew mr;Jv ( b1.__P „6 -NLC_J 5+0c(! ) Qce 1-1r - IDSc_ '13&ACh
cf--,- rnit)riC ' ,nfk I
Type and Dimensions of Project KkAA) 1'te-r" fil.,,d d oc .-- : Cro r 1 v VI cc_ d,uc k--)
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: ki0-1. Ti-) )
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doc-K trust be no Id' A i-o-\-A 1 of i ,,-
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Any person who proceeds with a development without the con ';-Jt�-47 . 111"0,a.G"
sent of a CAMA official under the mistaken assumption that the Applicant's signature .--RA.A.,4„at_co___i
development is exempted,will be in violation of the CAMA if there
is a subsequent determination that a permit was required for the
development. CAMA icial's signature
0 / 9 I 0 i
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 II ) 9 i o I
landowners certifying that they have no objections to the Expiration date
proposed work.
Attachment: 15 North Carolina Administrative Code 7K.0203

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•
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/UNCOVERED BOAT LIFT)
I hereby certify that I own property adjacent to "Town if O&M I k& l's
(Name of Property Owner)
property-located-at —- CQ,U Dr-
(Lot, Blockad, etc.)
on , in OCR Ts(e_ ea -V 1 , N.C.
(Waterbody) (Town and/or County)
He has described to me, as shown below, the development he is proposing at that location,
and, I have no objections to his proposal. I understand that a pier/uncovered boat lift must be set
back a minimum distance of fifteen feet (15') from my area of riparian access unless waived by
me.
I do not wish to waive the setback requirement.
`'/ Isk wish to waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
c3e.c col- -iecJ
Signature
GPP4
5\\
)R.
P t or Type ame
- C11 g 17 '7
Telephone Number
Date: '19 101
-30-

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/UNCOVERED BOAT LIFT)
I hereby certify that I own property adjacent to Tow N OF D eea.n 's
(Name of Property Owner)
property located-at---------_-- -- - ,QU.Se-I,3
Dr.
(Lot, Block, oad, etc.)
on , in (Ceara . 'fie. 'Bench , N.C.
(Waterbody) (Town and/or County)
He has described to me, as shown below, the development he is proposing at that location,
and, I have no objections to his proposal. I understand that a pier/uncovered boat lift must be set
back a minimum distance of fifteen feet (15') from my area of riparian access unless waived by
me.
I do not wish to waive the setback requirement.
I wish to waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
Gx,4-4-a_dn e d
VI
Sign, re
1S
Print or Type Name
579-96'i.�
Telephone Number
Date: 8-9-2W
-30-

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