General Permits (614)

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CERTIFICATION OF EXEMPTION - c
FROM REQUIRING A CAMA PERMIT
as authorized by the State of North Carolina,
Department of Environment, Health, and Natural Resources and the Coastal Reso rces Commission
in an area of environmental concern pursuant to 15 NCAC Subchapter 7K .0203.
Applicant Name Phone Number fir/
Address
City State Zip G
Project Location (County, State Road, Water Body, etc.)
Type and Dimensions of Project Ar
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.
SKETCH (SCALE: )
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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.
ant's signature
CAMA Official's signature
Issuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203
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I hereby celdlY ..t T Clkn rix4Arty adjacrnt to '?7
s
awe of Prope��iy !)wrier)
property lo�'�'t ._--.�j'.�� i
Ql fit, Block, Read,on
in
(Tow. and/or®axK�ty) — a W.C.
He has did Y �,P, as shown below, the develupwe11t t,is Pn)POsing at that
location, arid, I have r :ybjectinns to his proposal. I understand fax a must be set back a 3i,, ;iipium distance of fifteen feet (15,) from m at plecfuncovered boat lift
waived by me. y of riparian access zudess
I .chi OL wish to waive the setback requ cement.
I dQ wish to waive that setback requirement.
DF.Sf."tt,IPTIONi AND/OR DRAWING OF PROPO.SvD DRVLI,UPMENT•
(To 4e filled in by individual pmpoging dae!,O •��-F�
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PkAC,4a-
DEC 15 199-8
Signature
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R E:
Pant or T
�+pe Name P.
Tel hone Number
D

6 OIJ A C'�,,Lvr iR f
�k'A -�U'ATEMENT
:16'GA A #1EX',,7)VCnjZR
beli-Gy� :'tify Lt At I ovoi Property adjacent I to
s
NaniWof Property Owner)
property lc--;;.ted t
(1/49 Block, Road,
on �-v%v'
in
(Town and/or CountN. C.
y)
He has desciibed tu me, as shown below, the development he i proposing at t
location, and, I have no Objections to his proposal. I understand that a pies/uncovered boat lift
S rO that
must be set back a minimum distance of fifteen feet (15') from my area of riparian access unless
waived by me.
IUM wish to waive the setback requirement.
4Q wish to waive that setback requirement.
................
DESCRIPMON AND/OR DRAWING OF PROPOSED DEVELuPNIENT:
(To be filled in by individual proposing developnzenO
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Signature
k'nnt or Type Name
Telephone Number
Date:

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