General Permits (73)

T/7111cle-0 �o.
CERTIFICATION OF EXEMPTION
FROM REQUIRING A CAMA PERMIT V,
as authorized by the State of North Carolina, o 0
Department of Environment, Health, and Natural Resources and the Coastal Resources ission L'
in an area of environmental concern pursuant to 15 NCAC Subchapter 7K .0203.
Applicant Name �/6'X Phone Number J( -of 93
Address to
City &6& 14 State AIC zip
Project Location (County, State Road, Water Body, etc.) c.. // s r1-Z
Type and Dimensions of Project
The proposed project to be located and constructed as described
above is hereby certified as exempt from the CAMA permit re-
quirement pursuant to 15 NCAC 7K .0203. This exemption to
CAMA permit requirements does not alleviate the necessity of
your obtaining any other State, Federal, or Local authorization.
This certification. -of exemption from requiring a CAMA permit is
valid fo{ 90 days fro'Mthe date of issuance. Following expiration,
a re-exa`rffiMion of the project and project site may be necessary
to continue this certification.
I SKETCH (SCALE:° ) I
Aul,010 61 -C G �.
_PAC,PC 'e T !
Any person who proceeds with a development without the con-
sent of a CAMA official under the mistaken assumption that the
development is exempted, will be in violation of the CAMA if there
is a subsequent determination that a permit was required for the
development.
The applicant certifies by signing this exemption that (1) the ap-
plicant has read and will abide by the conditions of this exemp-
tion, and (2) a written statement has been obtained from adjacent
landowners certifying that they have no objections to the
proposed work.
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LAMA Uttic1ial's sjgnatureW!
Issuing date
jt y�O/
?3 f�ila " / /9? n
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

11
FOBOX 776 i'A?M1V0 COUNTY BUILDING 1NaiLL111UNa EAYBURU, N.C. 28515
[phone]
(after this form is completed by the land"-ner proposing the project,
a cagy is given to his/her adjacent landowr►ers for their Consent and
signatures. The forms are then returned, along with a building plan
and other applicable required %(iformati.on, to t�e wilding Inspections,
Uffice,for building permit application/ processing.)
ADJACENT KIPAFldN PROPERTY OWNER STATEMENT EPNQ
i Z1ErQbg certify that i otirp property adjaceat to
-��s O!1
Name of landowner proposing development body of water
in/nerlr:�_ Aho�� 1 4�Lrra r+ E' Lot1)of Si; -,oJO F,9rzm
community "��---�—
Subdivision, if applicable
Tax Parcel gaff 5 3��, GaMplete description of how u,
locate this property-,
The proposed project, a0 G u �k� and the location has been described tR me as shoia in the drawing below and i have no objections
to the proposal.
FOR A PIER, CHECK ONE Of •THE FOLLMNG:
ZI wish to waive the 15, mizlim,ff, setback from Amy riparian access.
1 DO NOT wish to waive the 15' Minimum setback requirement.
ii�rrR•rifRtfiiRtlfig:tttleR•Rttfrttrrf#**trs=rtrtrfryfr�*R*4trtRi►tR!•titr
Draw the proposed structure in the space provided belay. List the size
of the StMeture and messuxed distances from the adjacent property
lines, other structures on the property, and the road, water, etc.
f, - V
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01/19196 FRI 10:43 FAX [phone] TARRRn Aor