General Permits (374)

(D7)CERTIFICATION OF EXEMPTION
FROM REQUIRING A CAMA PERMIT
BP as authorized by the State of North Carolina, 4
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 �'; -! c^rut Phone Number
Address
City T<, State Zip 2 "7 6 1 - I0 A
Project Location (County, State Road, Water Body, etc.)
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 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.
I SKETCH (SCALE: )
I - { ._. _ I- J'_-_+_
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.
s sianatu
s sianature
Issuing date r
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

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AA�ACENi` kIP_ARxAN_ p�tpUPTy QWNER _SUTBMEft
r
Y h0reby certlty that .X own property adjwaent 'to
elm
Name
property
lapeted at �-0 3�
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(Ga , filoC , o� , etv.
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(Water. Nody (Town and/or County)
Na has degoribed to me es shoran below the development he is
proposing at that location and I have no objections to }iis
proyui�al. I understand that a pier must be set back a minimum
distance of £iftoon feet (151) £ram my area of rip&rian access
unless waived by me.
I do not wish to waive that setback requirement.
I da wish to waive that setback requirement.
be'oription and/or drawing Of proposed development: (TO BE
FrIs.I3b IN NX 11rDIVIDUAL PROPOSING DMMMPMENT)
ri ame
�OnNwUmber

,t
ADJACENT RIPARIAN PROPERTY OWNER'STATEME14T
(F011 A PIRR)
I I hereby certify that-1 own property adjacent
h Y 5�0 FAr2.w� o s
property
Name
located at C63 7SF�9 ►/,-J�U�-(L
( , on
00 RE C. oad, etc.)
_ ,u '. ICJ a l f% w i in
(Water Bod_v) (Town and/or 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 must be set back a minimum
distance of fifteen feet (15') from ny 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)
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Phone Number

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