Bartholomew (3)

1 CERTIFICATION OF EXEMPTION
K.. 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 ann, arr�iea of environmental concern pursuant to 15 NCAC Subchapter 7K.0203. a
Applicant Name 1(. ...e)4)r QI tl n� 3
Phone Number c�`O� 1z.
Address 1()g h i t IcAA
City State / Zip ,17S69
Project Location (County, State Road, ter Bod , etc. n C{ e ;_ ,
}t A.nF ?�K...' N1 Avg- m n
Type and Dimensions of Project P MY-0 tic-r'rd 'of-* LA)t-, (p' W tdu f\CCeSS
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: PJOT 7-0 )
'ot r,c veered e-k bra ck___
1ti-- 4(
aw -->ifc ot , leto_ f------->
44 w/ v, x‘ 4„rz. dQCk- 6ViA910n
t. -V, \O‘A1 0,44\ - k)r,T
_ Ate,
Any person who proceeds with a development without the con- ws' ../.�
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 V
r\ AA-ae..Q-Cu
development. CAMA Offici 's signature
1 CO 6
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 . 4 '} aU , t 1 (p6

aF c r
cr
,)'� VANCE E.KEE,MAYOR
/URF CITY ENDuNDGETHLAsNr:D.0. MAS,MAYOqpRp TEM^I _ ��ZBATTS,OOUNCtIMEMBERv MEDIIN,COUNCIA MEMBER
( �� LIONELL MIDGETT,COUNCIL MEMBER
/ HRjN LP RICHARD B.TURNER,COUNCIL MEMBER
NORTH CAROLINA 2 8 4 4 5 ROBERT KILROY.ATTORNEY
•
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/UNCOVERED BOAT LIF7)
I hereby certify that I own property adjacent to Fp ex) d, Dianna. p+hot0 me
(Name of Property Owner)
property located at of 3 g G Po a d k) 4. Si- e,e-t ,
(Lot, Block, Road,+tc.)
on Ca. nct.l , in Sur- Cti , N.C.
(Waterbody) (Town andl�r County)
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/uncovered boat lift
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 the 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)
Q80) 1n I oat Ski` \ j _.`
i
' o- .
t � e� ski � '� -� -�
R,-e Pa } - in� .oci- rofr fl ------------__/ 2ct,t
n,
60c„-t t
A /
-\ V _�/W Signature
- J e�C
C'a
p o CX- , k l , A r u Y /1/ e A/ iv
( �t-c,- i Print or Type Name
910 2 4 -- 3q -
Telephone Number -
Date: (, - 02 — 9

/F c '�
/yJ� i?'� VANCE E.KEE,MAYOR
TODD N.THOMAS,MAYOR PRO TEM
1. Q KENNETH D.BATTS,COUNC9l MEMBER
n �v!
A -V= DOUGIAS C.MEDLIN,
• 1 COUNC1l MEMBER
1`{1 . LIONELL MIDGETT,COUNCIL MEMBER
��[` �� ' (3 /URF C _ TY RICHARD B.TURNER,COUNGI MEMBER
0 wok NORTH CAROLINA 2 8 4 4 5 ROBERT KILROY.ATTORNEY
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/UNCOVERED BOAT LIFT)
I hereby certify that I own property adjacent to -R d-pelpblet 60.,irikbio rl ei 0
(Name of Property Owner)
property located at 9c3 g 6 r D a( 1,30. M-IA e. e ,
(Lot, Block, Rbad, etc.)
,
La_ n cL\ ,
on nn
le in ,Sur-c C i h , N.C.
(Waterbody) (Town and/or �ounty)
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/uncovered boat lift
must be set back a minimum distance of fifteen feet (15') from my area of riparian access unless
waived
by me.
V I do not wish to waive the 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)
i1 ` ! .L� Q ^
} I SE. .l�Ct-e-,,«�) ,
_~ Signatur
'CJoc- . SK % CO, n 3-ob.1y r.ebraIiw sL.
` Print or Type Name
t •
\ 1 , c-f
9193.2g11// o
Telephone Number
Date: 6 — 025- 9 g
T .._� ---- --