General Permits (683)

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,]K .02Q3__ _
,,
02
Applicant Name fJ�
Address
Citv '
Project Location (County, State Road, Water Body, etc.)
Phone Number v � 1 " -
11
State
Zip..` _ 4
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•NCAG�7,K-:0203: This exemption to
CAMA permit requirements does not alleviate the necessity of
your obtaining any other State, Federal, or Local authorization.
.�iCl
ISKETCH
� fA
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.
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.
(SCALE: - )
Ile
:✓ ..r�s�iry
Applicant's signature
CAMA Official's signature
i
Issuing date
Expiration date
Attachment: 1-5 North Carolina Adminisfrative Code 7K .0203
*1 1