General Permits (535)

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CERTIFICATION OF EXEMPTION
_Y 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 C'*'` t
Address ,
City
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.
SKETCH ",fit_ 1t 1.-..-.j r
Tit 611-1
A-`) rile_ �iQ,
Phone Number
State Zip t,
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.
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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Applicant's signature
CAMA Official's signature
Issuing date
Expiration date
(SCALE: )
Attachment: 15 North Carolina Administrative Code 7K .0203

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ADJACENT RIPAR-UN PROPERTY OWNER STATEMENT
(FOR A PIER/�nr lzrr ►n„. ,-,-.,,,,„ . ,�,
I hereby cer-dfy that I own property adiacent to 7-
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ame of Property Omer)
prope.^y located at ! a �/C
� � (Lot, Block, Road, etc.)
on q`y� � , in
N.C.
(Waterbody) (Town and/or County)
He has described to me, as si^,own below, the developmen: he is proposir._ a -
that a: location. -
an d, I have no obiections to his proposal. I understand
pilings/boatEf /boathouse must be se: back a minimum distance of � T- ff
Frte�n feet `r1`j" 117y �rta
of ripaIl= access unless waive; by me. j�Ay 3 Z002
I do not wish to waive the setback reauireme:<<.
I dr ,vish to wive t=at setback rec?11re,Tlent.
DESCRIPTION AN-D/OR DRAWLNG OF PROPOSED DEVELOF%rE'�7:
(To be fziled ir. by individual proposing �evelopme,,zf)
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ADJACENT RIPARLAN PROPERTY O NNI ER STATEMENT
(FOR A PIER/MOORING PILINGSIBOA 77-IFTIBOA THOUSE)
I hereby certify that I own property adiacent to _-5oV1 n n i P.) Lee, E� I c s
(Name of Property Owner)
propery locatd at
(Lot, Block, Road, etc.)
on VV0.Y'dt� 1vre-e.L , in r+ , N.C.
(Waterbody) (Town and/or C rity)
He has described to me, as Siiown below, the development he is proposi-= t,`at location,
and, I have no ob]ec�ons to his proposal. I understand Char- _a pier; mooring
pdings;boatifuboadl ruse must be sr-_ back a minimum dis�ance of fifteen fee; from my area
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IX I do not wish to wa%•e the setback re�uireme: t.
I wish to waive �.at setback rIncuirement.
DESCRIPTION AND/OR DRAWENG OF PROPOSED Doti)ELOr�Etii:
(To heJ=alled it by individual proposin; de ve pmqzr)
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Print or vpe Nam,-
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Date: