General Permits (402)

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CERTIFICATION OF EXEMPTIO
FROM REQUIRING A CAMA PERMIT ��
as authorized by the State of North Carolina, i;
Department of Environment, Health, and Natural Resources and the C astal Resources Commission
in an area of environmental concern pursuant to 15 NCAC Subchapter 7K .0203.
Applicant Name 4/ 1-" Phone Number L 3,Y % %
Address y
City State Zip
Project Location (County, State Road, Water Body, etc.)
Type and Dimensions of Project ! `/ ' t ,h
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
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 C
Issuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203
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ADJACENT RIPARIAN PROPERTY owm sTATF.!►�NT
_ (FOR A PIER)
I hereby certify that I own property.adjacent to
's property 'located at
(Name of Property. Owner)
(Lot, Block, Road, etc.)
on in ti���t�` Gt� v^'�� , N.C.
(Waterbody). (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 fif teen feet (151) from my 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 Ah'D/OR
(To befilled ir_by
06,5 1_
�00 130p ew
W I t3 'AP/
WING OF PROPOSED DEVELOPMENT;
ividual proposing development)
00CJc
Si nature
Print or Type Name
C� � (� (3-)_3>5�
Telephone Number

ADJACENT RIPARIAN PROPERTY OWNER sTATEtIIr.NT
(FOR A PIER)
I hereby certify that I own property. adjacent to
N Is property 'located at
(Name of Property Owner)
3.s O e7 C.A W,rvt� C-OT 2\ V N �£ �2tJ
(Lot, Block, Road, etc.)
on NP.uSc SZI*VE:(L , in C,2AVs,v C,ovNr7 , N.C.
(Waterbody)• ( 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 my area- of riparian access
unless waived by me.
do not wish to waive that setback requirement.
I do wish to waive that setback requirement.
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DESCRIPTION
(To be fil:le
-%,,--,.s0.�rV
ND/OR DRAWING OF PROPOSED
�r by indi tjidual proposing
T -ez �.
UYMr:NT :
lopment)
Print or Type Name
Telephone Number

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