Price (2)

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.—,O O
Applicant Name 3 ern, tnt 4 t 1l; e C r,Rtcsi Phone Number lo) 3S-0
Address p. u • 301( 7�
City 'S Ar 4b PeRizAt State NC Zip ,. 116
Project Location(County,State Road, Water Body, etc.) r7/0(0 ) I pv-t
49R1).1 -70Pl 'RPA I-I A/C.
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Type and Dimensions of Project no rX y' ice" - -hp Syr ric RP S;bkatx-P
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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:A/I
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Any person who proceeds with a development without the con- X ;/ 'e Yam,
sent of a CAMA official under the mistaken assumption that the Applicant's sig ature
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 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 J S-O¢
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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Locality Permit Number
GENERAL INFORMATION ,
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LAND OWNER
Name 3e wYj i/tI ' i LL;e. C •1;tr i Ge.
Address p. a• so X 74'r
5141n 0 v
City SNEVL1S reve3 State N.C. Zip Phone (9/03asd-350q -
AUTHORIZED AGENT
Name
•
, Address
•
City State Zip Phone
LOCATION OF PROJECT 7104) 11gb LGdeNve
Nor*h 7/5s4i, $eAc.l.t, N.C, ag'UOO
(If not oceanfront,is waterbody natural or manmade?)
DESCRIPTION OF PROJECT //p 1 X 414 ' I cll;t i ON
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AREAS OF ENVIRONMENTAL CONCERN (AEC) CLASSIFICATION
(To be filled in by the Local Permit Officer prior to completing application.)
Ocean Hazard Estuarine Shoreline N/ORW Shoreline Other
PROPOSED USE
✓ Residential Commercial/Industrial Other
SQUARE FOOTAGE OF BUILDING FOOTPRINT AND OTHER IMPERVIOUS OR
BUILT-UPON SURFACES (such as driveways, etc.) within 75 feet of the shoreline (575 feet
of an ORW shoreline) 1,72tUo I /(o
SQUARE FOOTAGE OF TOTAL FLOOR AREA OF BUILDING
SQUARE FOOTAGE OF SITE 5.000 •
OTHER PERMITS MAY BE REQUIRED: Zoning,Drinking Water Well, Septic Tank
(or other sanitary waste treatment system),
The activity you are planning may require Burning, Electrical, Plumbing, Heating and
permits other than the CAMA minor Air Conditioning, Insulation and Energy
development permit. As a service we have Conservation, FIA Certification, Sand Dune,
compiled a listing of the kinds of permits that Sediment Control, Subdivision Approval,
might be required. We suggest you check Mobile Home Park Approval, Highway
over the list with your LPO to determine if Connection, and others.
any of these apply to your project.

STATEMENT OF OWNERSHIP r
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I,the undersigned, an applicant for a CAMA minor development permit, being either the owner of property in
an AEC or a person authorized to act as an agent for purposes of applying for a CAMA minor development
permit, certify that the person listed as landowner on this application has a significant interest in the real
property described therein. This interest can be described as: (check one)
1/4an owner or record title, Title is vested in -Jerrl, It). D Lt.; C , , see Deed Book /3/0 ,
page30 in the © j Le to County Registry of Deeds.
an owner by virtue of inheritance. Applicant is an heir to the estate of ;
probate was in County.
if other interest, such as written contact or lease, explain below or use a separate sheet and attach to this
application.
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0
n.
NOTIFICATION OF ADJACENT PROPERTY OWNERS
I furthermore certify that the following persons are owners of properties adjoining this property. I affirm that I
have given ACTUAL NOTICE to each of them concerning my intent to develop this property and to apply for
a CAMA permit.
(Name) (Address)
(1)
(2)
(3)
(4)
FOR DEVELOPERS IN OCEAN HAZARD AND ESTUARINE HAZARD AREAS:
I acknowledge that the land owner is aware that the proposed development is planned for an area which may
be susceptible to erosion and/or flooding. I acknowledge that the local permit officer has explained to me the
particular hazard problems associated with this lot. This explanation was accompanied by recommendations
concerning stabilization and floodproofing techniques.
PERMISSION TO ENTER ON LAND
I furthermore certify that I am authorized to grant and do in fact grant permission to the local permit officer
and his agents to enter on the aforementioned lands in connection with evaluating information related to this
permit application.
• This application includes: general information(this form),a site drawing as described on the back of this ap-
plication,the ownership statement,the AEC hazard notice where necessary,a check for$50.00 made payable to
the locality,and any information as may be provided orally by the applicant. The details of the application as
described by these sources are incorporated without reference in any permit which may be issued. Deviation
from these details will constitute a violation of any permit. Any person developing in an AEC without a per-
mit is subject to civil,criminal and administrative action.
This the c 3 day ofSI5/241,14-671_ ,20 & I .
7.1)• ‘Pit;e.e)
d o.j'er or person authorized to act as his agent
#r purposes of filing a CAMA permi
t application.

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