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CERTIFICATION OF EXEMPTION
ti FROM REQUIRING A CAMA PERMIT
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 `S R l.4 IA L�I /U .�P r �l W,ISof Phone Number d k �"S— 7;
Address .-.2 ( `6 / 34 1 /tr- �C( .
City v State �_C, Zip a 6
Project Locatig,_1r (County, State Road, Water Body, etc.) 1 0 ' I 1 C444 if t.,ii(- i< S-1446R S 1Q; V-P r
A li 4A c.a A, ( 41 ( 1.341 DNS/0 t,,, ( 0 .
Type and Dimensions of Project '' vnkk%- 4C) t,AA.. et p is ri Crs.n Al i G Nivv-n..4
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- '4'--
sent of a CAMA official under the mistaken assumption that the r
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 ffi ' s sid tuts
The applicant certifies by signing this exemption that (1)the ap- / ��' ��
�tssumg 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 1—ji —0

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NORTH CAROLINA 28 •445
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
certi that I own property adjacent to_,it L e _ 1a��c e tte, is
I hereby (Name of Propelty Owner) v
� �� �� /Gr V /1y�eC
property located at o
(lot, block, road, or street address)
onr U . ,n ,5 j.niii , N.0
_ (Waterbody) (Town and/or County)
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He has described to me as shown below,the development he is proposing at that
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fl I location, and ! have no objections to his proposal
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}R DESCRIPTION AND/OR DRAWING Pt' PORPOSEP DEVELOPEMENT'
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Print or type name
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// ? ►t') .41wo 119. (c2.,...c.IL:2) S� - �S//�phone number
Date
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••••- .P -Box 2476`s -214 N. Nei/.River IJrive.4.. Telephone [phone] • FAX:.4 ).:328-a132.
** TOTAL PRGE.k 2 *4,

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NORTH CAROLINA 2 (3445
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
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I hereby certil� that I own property adjacent to—S tr1 e _ gike)/e
(Name of Prop Owner) il
' UhvreLo4* iIV
property located at.._,C�j.�--).G✓ r�..
(lot, block, road. or street address)
4-er �, �1 � , 34-vT 51.c0141 _ , N.0
an / ---` in ,
(Waterbody) (Town and/or County)
t6' �,GK
He has described to me as shown below, the development he is proposing at that
I location, and I have no objections to his proposal
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1 DESCRIPTION AND,'OR DRAWING PF PORPOSEI) DEVrELOPEMENT'
i/= (7t) be pea in hN rrrrlrvidira1 proposing dokeleipmeo!
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Pr°/�osa� 1) tk heed M 1
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Like exitft✓ lbv)K he4s ,___
r74 pE oik wood Lu M 60- Print or type Warne
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Telephone number
Date
. --. "BOX 24 5'-• -214 N. New River Ori .* Telephone (910) 32a-4131 • FAX-i t028-a132,
,4 TOTAL PPCE.02 *,r.