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CERTIFICATION OF EXEMPTION Pc w LLSZ--
FROM REQUIRING A CAMA PERMIT11(9,1114) 2_cde:tp-
as authorized by the State of North Carolina, - id CJr� • oZ Lk
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 �� �� Phone Number
Address /ft
City ff o ". ., 45K..�.,- , State Zip t—
Project Location (County, State Road,
,Water Body, etc.) (,1
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Type and Dif 9nsions of Proje�ryt R l( 00 khead c 4`). 4 /14' k4 /e/A �,/5(4--/i,
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Ail Con l4'1.)ny aF 9k • Dam3 ck4 // qp ,
e proposed project to be located and constructed as described This c'ert�catiion 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- _
sent of a CAMA official under the mistaken assumption that the Applicant s sf nature
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 Offic' I's sre
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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 /

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OrVIstON OF COASTA 1 .CF;4E T
ADJACENT R:mARIA.:r PRC?ERTY OWNER NOTI7:CATION/74,I7=R FOPL!
Name Of Individual Applying For Permit: Ld ,
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Address Of Propert: //,R iioki cS-b CY I -
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(Lot or Stree r, S�.redt o_.Road, City & County)
I hereby certify that I own, property adjacen,t to the above-
- referenced property. The individual applying for this permit has
described to me as shown on the attached drawing the development
the,/ are proposing. A description or drawing, - with dimensions,
should be provided with this letter.
• I have no objections to this proposal .
. . If vcu have objections to what is be inc c occsed . Tease write
the.
Division of Coast_l Ma perenL . 127 Cardinal C`_vo Extension ..
Wilrinctor, . North Carolina . 2 405 cr call S10 355-3900 within 10
days of receiot of this notice . No resmonse is considered the same
as no objection if you rave been notified by Ceram f a Mail
FrAIVIR SICTION
I understand that a Die:, dock, mooring pilings, breakwater, boat
house, lift or sandbags must be sat 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 a_: ia_e blank
below. )
I do wish tc waive the 15'setback requirement.
I do not wish to waive the 15 'setback requirement.
Signature Date
///tea/ 4''w,5 C.0 ��,'
Print Name i
Telephone Number wit;t Area Coda CD�HNf=t