General Permits (722)

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CERTIFICATION OF EXEMPTIO_ W Ico
FROM REQUIRING A CAMA PERMIT �� .�� 12� 1 air
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 c
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.
State
Phone Number , - 7 C �` 5
Zip
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:, ;, )
is - �?y.a '"': r: i 'h11J L •. i_c , r
(_
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.
t7'
CAMA Official's signature Y
Issuing date
Expiration date
_ry
Attachment: 15 North Carolina Administrative Code 7K .0203

ADJACENT RIEPARIAN PROPERTY OWNER STA`i 11EN-T
SC�
Z hereby certify that I own property adiacent to 's
(.IN -awe of Property Owner)
proper y lccated at
(Lot, Bto
Road, etc.)
-Ck . N.C.
Oii �.A�J��i1+�.�'� In V R �l\� i41r�
C Waterbody) (Towu and/or County)
He has descnoed to me as shown below, the development he is proposing at that locanon;
and, I have no objections to his proposal.
DESCRIMON ATN-D/OR DRANNTG OF PROPOSED DEN-ELOP.4ECNT
(To be filled in by indiv&ual proposin, development)
A21 / � T- �--' —s% 7
iQnature
Punt or Tvce Nam -I
Telephon: N--;,,be;
Date_ ..2 000

.-DJAULIr Y H FAFJAIN rRVt`#...Ki' Y U YY a x 1 r.IVMI'i i
SoX
?L'
I h(--: e:)y certify that I own prope-ty adjacent to
prc,pei ly local j at
S
(Lot, Btock, Road, etc.)
(Name of Property Owner)
kMaterbody} (Town and/or Coantv)
He has described to me as shown bellow, the development he is proposing at that loc-%non,
and. I have no objections, to his proposal.
DESCRIPTION AND/OR DRAi'VTNG OF PROPOSED DE ELOPNIENT
(To be filled in by individual proposing development)
r
Sian tore i7
'�Drx L, �30X, Jr.
Print or T•.--Lle Nane
Telephone
late: