Van Story

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.
Applicant Name VA-NJ, SIP �/o F 5 Mgt l Phone Number ; Z .�� (-s .
Address (q it 7 S. �'1 Fs t-�t-�a
City * J i i _Irv— t ._..,-- ., State ._ n �Zip 2 1 t
Project Locatio9(County, St oad, Water Body, etc.) -Pt7 _ ! - k YT"ildy—S
(k) i NA Er...) Jtom/ C"-
Type and Dimensions of Project
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: 1 )
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Any person who proceeds with a development without the con- -/A-4f'Lw `,,
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 r
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is a subsequent determination that a permit was required for the ` ' `�
CAMA Official's signa ure
development.
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 3_ pZ

DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION & WAIVER FORM
Name of individual applying for permit ( / /fin J LY-/Z/
Address of property (' ) /31'T�4 I11'111! Jt�L't'A
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 they are proposing. A description or drawing, with
dimensions should be provided with this letter of notification.
Please initial below if you have no objections. (3Kl4iiC :iffi!/Rrkrn ,ry
I have no objections to this proposal.
" "' Fi`t<'u"'�
J p p
If you have objections to what is being proposed, please write the Division of Coastal
Management, 127 Cardinal Drive Extension, Wilmington, N. C. 28405 or call 910-
395 3900 within 10 days of receipt of this notice. No response is considered the
same as no objection if you have been notified by Certified Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater,boat house,lift or
sandbags must be set back a minimum 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.
I DO NOT wish to waive the 15' setback requirement.
/ Aae � v Signature & Date
C-6 e` C . Ci m� Print Name
ysr - " Ads —
Telephone Number w/ Area Code
A
PLEASE SIGN AND RETURN TO; F&S Marine Contractors,Inc.
-ot BDpj.
P.O. Box 868
.17 ��),-- Wrightsville Beach, N.C. 28480
--n g75) _24th y 199 p- Phone/Fax [phone]

DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION &WAIVER FORM
Name of individual applying for permit l LL /41 j 6r
Address of property (-7 ) /J�1 -Q [ V
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 they are proposing. A description or drawing, with
dimensions should be provided with this letter of notification. -34iiiic,“ ), k�,4
Please initial below if you have no objections. �
�1 C�f%►� Pliicra L'•
V
itL-GC— I have no objections to this proposal.
If you have objections to what is being proposed, please write the Division of Coastal
Management, 127 Cardinal Drive Extension, Wilmington, N. C. 28405 or call 910-
395 3900 within 10 days of receipt of this notice. No response is considered the
same as no objection if you have been notified by Certified Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater,boat house,lift or
sandbags must be set back a minimum 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.
I DO NOT wish to waive the 15' setback requirement.
,✓� ,�ji � � ��r�- Signature & Date
iv m 6)(2 c c�) i
, Print Name
�► I/ 1 — Th ✓_ /© / Telephone Number w/Area Code
PLEASE SIGN AND RETURN TO; F&S Marine Contractors,Inc.
P.O. Box 868
Wrightsville Beach, N.C. 28480
Phone/Fax [phone]

F&S Marine Contractors, Inc.
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Soap' P.O.Box 868
WrIgh'`U 28480
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