Young (4)

' T CERTIFICATION OF EXEMPTION r
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. „ v .
Applicant Name �k ., Cv/11.,(96'/`I /v1/�n,tC lv SI4IWP / (/ 1,PA.vtti- Phone Numbe(1 ) `�J >%a��
Address .,, by t,i,), (ciGA t bP, v e
City /kAwv.-AT.)w r- Sate A, C Zip :T1/6 .-
Project Location (County, State Road, Water Body, etc.) - /"ir S,dn .Sll 9L i ci& ^ ,
4ke�%' u( rst,�l r i/ ye" , t3.Gi cH ;UC re)
Type and Dimensions of Project (fl- ci(2 k C-1 v� v it Aer v 0 fa; (-le6 XS"a
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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- N(,(44/
sent of a CAMA official under the mistaken assumption that the pplicant' sign re
development is exempted,will be in violation of the CAMA if there , Il
is a subsequent determination that a permit was required for the
development. CAMA Oftilas s g ature
The applicant certifies by signing this exemption that (1)the ap- Issuing date 6 �/
plicant has read and will abide by the conditions of this exemp-
tion,and(2)a written statement has been obtained from adjacent 7/)/9f3

17° -
OE. 21 . 98 O9 : 4 .AM 7CRD 049 1 NC FAYETTE F' 1
ADJACENT RIPARIAN Y'?O�ERTY OWNER STATEMENT
A I.L N;i DOCK
I hereby certify cwn i'::cperty eic;:aces: .
.c a}ed a-
J _ t
, etc .
(water bgdyi
North Carolina . He Hag ces- c1J:Jed me es sn-own tip _
development he is propos: a.:- that .ocat ion and I Nave no
obJectic',ns to h's "oho- un ters ara that a pier must t e.
set back a minir.tT list ancR cGf . , fees
riparian acceso unless waived ty rye : I cco
-461. .re s eoa :Y.
Deice 1pt tor: end/ dL'aw_rtg of proposed development.( c
be in by props ''{ny development )
1 i
5i g r t u r e
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Name °�n --2 h 7 '7 a.7

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
PIER/FLOATING DOCK
I hereby certify that I own property adjacent to
IJ� *t)It 5 ' s, property located at
.263R 1,0114ca-1-- ()1tt' 2
II ( lot , block, road, etc. )
on Jti) 1d CG+ on Holden Beach
(water body)
North Carolina. He Has described to me as shown below the
development he is proposing at that location and I have no
objections to his proposal . I understand that a pier must be
set back a minimum distance o9f 15 feet from my area of
riparian access unless waived by me . I do/t not)wish to
(circle one)
waive that setback requirement .
Description and/or drawing of proposed development : (to
be filled in by individual propsing development )
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e Signature
Name
a'va- 3 2 /
Phone Number