General Permits (612)

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CERTIFICATION OF EXEMPTION C\vt,`;
FROM REQUIRING A CAMA PERMIT �d
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
City
Project Location (County, State Road, Water Body, etc.)
Phone Number (_- 5t
State w C zip
VA
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.
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SKETCH (SCALE
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Any person who proceeds with a development without the con- t '
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.
t'2 F .
Applicant's ignature
CAMA Official's signature
C`G
Issuing date
. C-
Expiration date
V.
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Attachment: 15 North Carolina Administrative Code 7K .0203

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER)
I�—heereby certify thatI own property adjacent to
;I�k- S's property
Name
located at 16
M6t, B
, Road, etc.
on
Rlueo 1319-.4 !A 10E in /U E�o 13J;4w, C.,p,Usa N. C.
(Water Body) (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 (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 and/or drawing of proposed development: (TO BE
FILLED IN BY INDIVIDUAL PROPOSING DEVELOPMENT)
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}dam ignature
Name
Phone Number

Hh — 0 -A —09 0 , ; 56 Hill
04/09/1999 15! dd FCLFV 4ND FOLEY lh�:
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own Property adjacent to
Is property
4 1
rAM%P-V;LQGKP Roac, etc., ;,. i
in AJAw
_TN—wn of County)
ACS11-2hown below the development he is
P4A-tA,0 and I have no objections to his
PAT 01
, on
T9,
�5 mat a pier must be set back a Minimum
AM n
(15') from my area of riparian accesir.
'W
Uve that setback requirement
;* 10 #,V4 bat setback requirament.
.0W#9r of proposed development
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Phone Number
04
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