General Permits (779)

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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 1b NCAC Subchapter 7K .0203.
'' CG
Applicant Name. I -t i t _ f
1 Phone Number , c'J�
Address
City
Project Location (County,
Type and Dimensions of Project
Road, Water Body, etc.) .
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
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'--- 1 `_ (SCALE: A. I -Tr77 )
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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.
Applicant's signature '
CAMA Official's signature-
. i
Issuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

--`-- — ADJACENT RITARI.N PROPERTY OWNER STATEMENT
I hereby mtify that I own property adjacent to 9 C, G• e,- Ra r ty?-c; (.mot -4er- 's
ame of Property Owner)
proper located at Sa ! We � 1 6lu 1 4-
(ot., Block, Road, etc.)
on Cy r r _s in
(`Vate--body) (Town andlof County)
He has descnbed to me as showm below, the developmeit he is proposing at that location,
and, I have no objecrions to his proposal.
DPSCRIPT ON AND/CAR DRAWNG OF PROPOSED DEVULP:N��"T
(To be filled zn by individual proposing development)
_ . P.°R 1 _: 2001
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Sipature
Pant or Type Name
Telephone Number
,� Date: ___/-'
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--- -----M.DJACENT R PARS' PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to POr�� r�4 •�°�'� 's
(Name of Property Owner)
property located at .5-a l We 61 6 u -� ,
(Lot, Block, Road, etc.)
on�®o.� e �r r , is /�i� , N.C.
aterbod own andlof County)
He has descn`bed to me as shown below, the de-✓elopment he is proposing at that location,
and, I have no objections to his proposal.
DESCPI MON AND/OR DItAW NG OF PROPOSED DEVELOPMENT
(To be filled in by individual proposing development)
APR 1 - [uui
0 l 4 U-XC I r '�' 4J G e� i" 1' ►^ e q U&, 40. 4 P re'&' yp'W �.
(,lea i k ors 4M l t n 0 w K
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Sidnatare
Print or Type Name
7 _33 c�
Telephone Number
Date: