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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.
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Applicant Name I t� B\A C§✓ Phone Number Dc c�" itJ
Address �1 �-f'r'ecl-
City +�G ,` *•Cf C SkeP �.t'lil) State 1. Zip O 4 -�
Project Location (County, Sta a Road, Water Body, etc.), D n S I o� (o U 905�1 C1 ,
4th c j NC) , f, n—Msic i %r, 1 7
Type and Dimensions of Project tJe,AJ c'k- Lep`X 30' f r 4 he_ ti ,3 A If.. 'L xC Iasi ICJ
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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- •-- 7f3.:;_. d.
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 I
is a subsequent determination that a permit was required for the
development. I CAMA Official's signature
The applicant certifies by signing this exemption that (1)the ap- Issuing date 1
plicant has read and will abide by the conditions of this exemp-
tion,and(2)a written statement has been obtained from adjacent -�3 f \ Qtq lV

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DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER- FORM
Name Of Individual Applying For Permit: 4 m
Address Of Property: l 1c,'
(Lot or Street #, Street or Road, City & County)
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.
✓ I have no objections to this proposal.
If you have objections to what is being proposed, please write the
Division of Coastal Manacerent, 127 Cardinal Drive Extension,
Wilmington , North Carolina , 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 distance 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' I do wish to waive the 15 'setback requirement.
I do not wish to waive the 15'setback requirement.
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Sign ure N
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Print N + I / SD/ `� �/ 1•„
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Telephone Number With Area Code

DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVEB_ FORM
Name Of Individual Applying For Permit: �� AMC)-{
Address Of Property: ` ''
(Lot or Street #, Street or Road, City & County)
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.
I have no objections to this proposal.
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If you have objections to what is being DroDosed ,• plea_se write the
Division of Coastal Manaaement , 127 Cardinal Drive Extension ,
Wilmincton, North Carolina , 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 distance 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.
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‘,40' Aiat-JW
Sicna e ur Date
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/M/1'4 M !fir //are �_
Print ame
Y/0 - 93 - 7a8'a H R
Telephone Number With Area Code