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CERTIFICATION OF EXEMPTION
_The.._H
FROM REQUIRING A CAMA PERMIT (;, /° S ' Sas 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 Aso t4 " S /N I, /( Phone Number
Address I ( T5/4N i) 00 Li-to
City I ( R i State n/( Zip Jd 51Y3
Project Location(County, State Road, Water Body, etc.) 54rt.../ 4,-// 44 Cam,/ --vnJ4• / S0,41 ()
/ .?"es-h-.4,G J
Type and Dimensions of Project ViX , v!t'7,. -6oc'c "] ' yJ S
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: )
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Any person who proceeds with a development without the con- e
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 I%y j �� ��
is a subsequent determination that a permit was required for the -'� � '
development. 7-CAMA Official's signature
The applicant certifies by signing this exemption that (1)the ap- \` I 1 l°> U j
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 f c") - /`) - `) I
landowners certifying that they have no objections to the Expiration date
proposed work.
Attachment: 15 North Carolina Administrative Code 7K.0203

DTYISION OF CEOeLCTA7 MANTA G xN-E
Na
Name Of Individual Applying For Permit: /U ao dq,;, Si/c
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Address Of Property: /// -7 Si ,.v� 2 4_
(Lot or Street#, Street or Roa , City & County)
I hereby certify that I own property adjacent to the above-referenced ro e
P P rty- The individual
applying for this permit has described to"tie as shown on the attached drawing the development
they are proposing. A description or drawing, with dimensions, should be provided with this
letter.
OL q,.,ao Id)opci
CSIJ I have no objections to this proposal.
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Manag m n , 1�7 1`Torth f aT�;,,�� 1}ri wilminotnn -
•thin 1[)davc •of recpint •of t1,' oncidPrP� rt,
---y �c notirn N� r cnonc is
if you have been notified by Certified Mail
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WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boat house, lift or sandbags 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.
. c4ipI do not wish to waive the 15' setback requirement.
ap k0V. 7a , /1/ P/gO/
Signature Date
1111
dinstangye At /i�s�� // „.„An74A,
Print Name
(9/0) ? 2S'- /?,2y DENR
Telephone Number umber With Area Code NORTH CAROL,,,,,DM..oRrM�r OF
` ENVIRONMENT AND NATURAL.RE-SOURCES
((a7- S.. .�opsail ofIve Lot 37-
Surf Cy, OVC a �tiVS .r51ar+c0 dce(<s

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XCATION bz
Nye Ot Individua
l Applying For •Pe-
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m3tc ooje Od4/ .‘
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Address pf Property!roperty.
(LO°r stye , Street Or ��
��d v City OC Cp
YErebY certify; Y)
tY that
r €erehce� Z oe Property adjacent
rmit has
dascrenc d property. _ The individual applying
this
the
they to me as shown on the pplyi�yg for this Ztboyg,.
are proposing. A. description orattacheddrawing,draw th¢ d men ant
should be.' provided with this T Iet��__ with dimensions,
A`-al: I have
Aiwa' �°xh?ec�tibns to this pi'cposa1.
�Vvu have vbiect on to what a..00� '�?r'°1 �./'�-e'/..�►.iir.4¢
• w.. 4�'`e4a of N�aL� C2 e n s ent� i�_7 c C a�osd . b ea a .t
r r a ar d4 sHO-- the
�" f r ce�b o f 8 �- o
_tel, b1ect'o s not'ce_ Nor soon @ .-0 9�- 0 y,,' h
�--�•- � i f v gv ea 10
nd i e lay C_. S f dew®d. t me
�ga_Mai i
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= understand that a
house, lift pier, apse mooring pi2ar�gs bra_
frog my area of ripo Must ba set back a minimum stances, boot
from
towaive tine rip ian access unless waived bydistance of s11
wl, } • you m- ,'t . initial the apu . (ia. e w_sh
t PpraPrir�t>r blank
•
=-ia_.._ r do wish to waive the S fsetback reouiremint.
wish�- Z ao is wish to waive the 15'
Setback reouirea%erit.
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phone Number Witj� '"�� '�'"��
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