Due

CERTIFICATION OF EXEMPTIONN.7---.'
` / FROM REQUIRING A CAMA PERMIT Q S
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 b b o r' k J v c Phone Number
Address O 1 ,3 04 h P(. E:,5±
City D a i l:;„ j State Zip
Pro4ect Location (County, State Road Water Body, etc.) (t.A..'--- -(--.--1 1 a 1/.e ,,Q a ✓1 c.Lc ti L D A13,141 tour
`7 -,.1 c ).1 1 13 1'siF 5 wig=k roc' ✓n f /
Typean Dimen$ions off Project Cn✓�5-irJc -1 (o ' ;< / j� ' pier n10 0ni1/i) o..,,,,i c/.- r.+St, ' ,
„11'1 n-a T ieV/ chF h4 .,1✓�(, �- /741 -�- s Am // n-a t P )( te'c' M ter{ �''+a rr
l/ ly I 1"
W t ct i+' o f J -y-iir u is 4rr h o d,i
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: tJ 4- c„k )
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Any person who proceeds with a development without the con- '`'� �—.���� ti
sent of a CAMA official under the mistaken assumption that the ,ppiic t 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 (71 • "`���
development. CAMA iciaP signature
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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
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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Name Of Individual Applying For Permit: E - _ _.
Address Of Property: a
)e c N-\I
(Lot or Street i, Street or Road, City & County)
I hereby certify that I own property adjacent to the above-referenced
applying for this permit has described to be as shown on the attached drawing The development
they are proposing. A description or drawing, with dimensions, should b�provided the de with his
letter. with this
I have no objections
J to this proposal.
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if vnT, have h��n nnr;f;P�l �, r
v l ?TrtT,on wT
I understand that a pier, dock, mooring pilings, breakwater, boat house, lift or sand
set back a minimum di. nce of 15' from my area of access bates must be
wish to waive the setback, you mast initial the appropriate r unless waived by me. (If you
blank beIow.)
__ I do wish to waive the 15' setback requirement.
I a-nor wish to waive the 15' setback requirement.
Ar
a o ( ' 3 -el il
Date
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Print Name
i 0 --- -2 - 5-0 l NCDENR
Telephone Number With Area Co
de
NoRTri Ca A N Dom' �`LNT of
AND ND NATURAL RESOURCES

�4STAi ,e ,
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. Name Of Individual Applying For Permit; _
Address Of Property.
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(Lot or Street#, Street or Road, Ci
I hereby certi �' & County)
fy that I own property adjacent to the above-referenced
applying for this permit has described to be
as they ng proposing. A description or drawing,shown on the attached drawing•the de individual
letter. with dimensions, should be eg development
pment
provided with �;s
I have no objections to this proposal.
CTP a
if van havA boon nntifiPri 1, , r�
I unders�nd that a pier, dock,back a m L, mooring piithas, bream,water, boat house,
minimum d�Ce of 15' from my area of lift or sandb o
set wish toc waive the setback riparian accessa�s must be
you mn. initial the appropriate bbla unless waived by me. (If you
blank: below.)
•
_. I do wish to waive the 15' setback requirement.
6-11-:
I Lio nQt wish to waive the 15' setback requirement.
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AT
igrature
��FF�,� Date itivri
Alimmiummeml
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9i y 88/ _ o � �
Telephone Number WitNCDE
Area Code
NoR'7„
E�1RONy �R.7LJNA Dc?'�iTpLNT OF
err AND NACruRti RESOURCES

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