General Permits (393)

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.
Applicant Name
Address
Citv
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.
Phone Number
State
Zip
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: )
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.
Applicant's signature
CAMA Official's signature
Issuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

i
STARBOARD
0
ca
c�
pN
TON DRIVE
z No�M
VICINITY MAP
L�
Ward4
11ropeir�
I
1
a''
Ow
A¢

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to Jan & Joe Griffin
property located at 106 Starboard Circle
lot, block, roa�,etc
on canal to Whitaker Creek in riental
body of water town
North Carolina in Pamlico County. The proposal has been described to me
as shown below; the development,a.pier/bulkhead/structure, and the proposed
—circle one
location, and I have no objections to the proposal. I understand that if the
development is a pier, it must be set back a minimum distance of 15 feet from
my area of riparian access unless waived by me. I d do not wish to waive
that setback requirement. circle one)
Description and/or drawing of proposed development; Indicate the size and
location of the structure and the distance between each property line and
the water.
2..
0i
C
� ^J
.Y
�31 l
(original must be retained in the inspections department)
- , 2 cl J
please print

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to Jan & Joe Griffin
property located at 106 Starboard Circle
lot, block, road, etc.
on canal to Whitaker Creek in Oriental
body of water town
North Carolina in Pamlico County. The proposal has been described to me
i'1 d d iZ r 1v6 e -S
as shown below; the development, a< -rttctttre, and the proposed
circle ones—�
location, and I have no objections to the proposal. I understand that if the
development is a pier, it must be set back a minimum distance of 15 feet from
my area of riparian access unless waived by me. T d do not wish to waive
circle one)
that setback requirement.
Description and/or drawing of proposed development: Indicate the size and
location of the structure and the distance between each property line and 1
the water.
/sX VO
O 5`e c
+A,e V.
(original must be retained in t�he� inspections department)
signature—zLad date
name please print
'-A�

1)1AJeJ1VF- 06AIAItltort
J 4
k",