Worthington (3)

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 Phone Number
Address
City State Zip
Protect Location (County, State Road, Water Body, etc.)
ron
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:
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Any person who proceeds with a development without the con- /(/f"
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
is a subsequent determination that a permit was required for the
development. CAMA Official's signature
r;
The applicant certifies by signing this exemption that (1)the ap- ��v l ��J
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 , 'q
lanrinwners certifvinn that they have no obiections to the Pvniratinn Hata

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o a a o t HA Post Office Box 3089
Topsail Beach, North Carolina 28445
Telephone [phone]
•
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER)
I hereby certify that I own property adjacent to
/e0/ k10,C77jrt,ieG144 's property located at 9$47 4)/14
(Name of Property Owner
t o ocdd', oad, etc.)
on , in
N. C.
(Waterbody) (Town and/or County)
He has' described to me, as shown below, the developement 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 of fifteen feet (15') from my area of riparian access
unless waived by me.
I d not wish to waive that setback requirement.
I 'do ' h,,too waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
5'O / L anif X.' Gfi ce F•ijs c. P,e CP-441- j
COnwocc4• (sc. dieArj,*iy on) Avertse.f;d&
Awinf-
Note: If you have any questions, please contact Robert Kirkpatrick
at 919/686-4561.
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Pi o p M Post Office Box 3089
`► r`�' ' �'=^ Topsail Beach, North Carolina 28445
Telephone [phone]
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER)
I hjreby certify / that I own property adjacent to
20A/ IkerAvIN473,J 's property located at ti(7 hilt'% ej C tg
(Name of Property Owner
(Lin, blocK, Koad, etc.)
on , in , N. C.
(Waterbody) (Town and/or County)
He has described to me, as shown below, the developement 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 of fifteen feet (15') from my area of riparian access
unless waived by me.
I do not wish to waive that setback requirement.
I do wish to waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
re) te.4.0V KS1 n A-714,c, 0-7-4.4,7;4-1)
U—- vatic., :,t s iZ�. !�!' �f J c e rw,,,f o A' t.N--£
JZ) 4 4Aigt-asialvi u-
Note: If you have any questions, please contact Robert Kirkpatrick
at 919/686-4561.
(-40.4421, je_ears----
Signature
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