General Permits (173)

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 Resour mission n
in an area of environmental concern pursuant to 15 NCAC Subchapter 7K .0203. (6P
i
O
Applicant Name
Type and Dimensions of
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 for 90 days from the date of issuance. Following expiration,
a re-examination of the project and project site may be necessary
to continue this certification.
SKETCH _ ;% (SCALE: mob= ) I
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.
Cr -71 S�v•►
CAMA Official's signature 4j
/ ?_ 9 S
Issuing date q(a
i- -3 2''
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

e � i
ADJACENT RIPARIAN PROPERTY MWER STATEMENT
I hereby certify that I own property adjacent to
Vic;--X a2-
's property located at
N�f Property owner
6
(Lot, Block, xoaa, eLc.)
in l�J� S .� �� �� N.C.
erbodY) (Town and/or C unty)
He has described to me, as shown below, the development he is
proposing at that location, and, I have no objections to his
proposal.
----------------------------------------
DESCRIPTION
(To be f i 1'ie
in
OR DRAWING OF PROPOSED DEV
by individual proposing de
f4
MOPMENT:
y,,elopr�e t) j
r�
Signature
Print or Type Name
- J � - J 2-
Telephone Number
46elk

ADJACENT RIPARIAN PROPERTY Oh'NER STATEMENT
hereby certify that I own property adjacent to 2,Ff r
's property located at
(Name of yrop6brty owner)
v (Lot, Block, Road, etc.) / ff�
on li /Isi►� in < /� XC/ . N.C.
(W erbody) `(Town and/or C ty)
He has describe to me, as shown below, the development he is
proposing at that location, and, I have no objections to his
proposal.
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DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing d elopment),
r
fAM �
a
�o Gory
f
Signature
prirft or Type Name
Telephone Number

ADJACENT RIPARI
I hereby certif that
PROPERTY OWKER STATEMENT
I own property adjacent to
s property located at
(Name of Propert Owner
/ (Lot, Block, Road, etch.)
or���,�// �l�AS%2%�k �`��z-c� , in l' 61 /�� t , N.C.
aterbod (Town and/or C y)
He has described to me, as shown below, the development he is
proposing at that location, and, I have no objections to his
proposal.
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DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing de elopment)
hex,",
-�
Al ,
Sign ure
Print o Type Name
7,�'g %�/
Telephone Number