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• CERTIFICATION OF EXEMPTION
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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. �_1
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Applicant Name ;'+1y4;t ➢o vt L i /u Gk't G 40 I hg•'- Phone Number `nu) i `J 97 3 i
Address , I(, L v(ti rot•A '-r -)9;0-7
City r i, •i State /v C Zip 7�I C-11
Project Location(County, State Road, Water Body, etc.) Pi 7 S!.t-M'I , . I al--- 4-.04T 14 1
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Type and Dimensions of Project 7v 1 ,in//<l<e4 ;) , 6 ye, ' fit. 'P r 6- 'y/b ' >�l 64 -'
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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.
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Any person who proceeds with a development without the con- fj
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sent of a CAMA official under the mistaken assumption that the Applica'ft't' ign
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 ial's 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 - 9 4
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DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROpEu� W R NOTIrICATIt3N�WVv,R FORM
Kama Of Individual Applying For Permit: C �;
Address Of Property: l 4C1 6 a c .
(Lot or Street 0, Street or Road, City & County)
I hereby certify that I own property adjacent to the above-
referenced property. The individual applying for this permit has
described to me as shown on the attached drawing the development
theyt are proposing. A description or drawing, • with dimensions,
should be provided with this letter.
/27c7 I have no objections to this proposal.
I you have cbeg=
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s � inc 9;CCQsed< rls:sa �.:;its the
W, / nrrtr�Tt nto►yn. Carolina 28405 or cal I 91 h r
gs no obleo_tion if you Nava been notified by Certified Mai:
WAIVVR SECTIOA
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:ial the appropriate blank
below . )
I do wish to waive the 15 ' setback requirement.
.�_ Igo no% wish to waive the I5 'setback requirement.
Signature Date
P.. i t Name
•••...`..ram
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Telephone Number 'w i ch Area Code

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