General Permits (920)

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CERTIFICATION OF EXEMPTION �''�3 ~ �`
�r FROM REQUIRING A CAMA PERMIT
as authorized by the State of North Carolina, g
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 t ( cu
Address f ,c
City
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.
Phone Numberz�25,�)(-- ti - y1�
State zip %lb
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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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Any person who proceeds with a development without the con-
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t of a CAMA official under the mistaken assumption that the / AF
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development is exempted, will be in violation of the CAMA if there _ i
is a subsequent determination that a permit was required for the �V�
development. CAMA Official's signature
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 Expiration date
proposed work.
Attachment: 15 North Carolina Administrative Code 7K .0203

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ADJACENT RIPARIAN PROPEMM OWNER STATENUWr
Iheaby car* tt,Wt I own ps,a7Pem adjumt tb
kv-�amr�Qfprovcro�S
owner)
Prupay locamd at
apt in
(Waterbod� C N.C.
(Town and/or Udy)
He bas do dbad m tie u shown below, the davntoprnent he is pivpos€nr at that iocsfon,
afld, I have no objeadons to his pt pvsal.
DESCRLMON AND/OR nRAWD% OF PROPOSIM DEVELOPbU NT
(ro be,j ed in by imovibapftpG$'n,f dav&Wvu gt)
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Teleph(me Number
Date:

' JUL--03-2001 TUE 10:20 AM NO DIV OF CUAS'I'AL 1 OM' MA NU. C241JJJU r, Ue-
A.DJACFNT RIPARIAN PROPERTY O WNRR STATEMENT
I hereby certify that I own property ad ==t to .4A/Z /.4y/Ge& �g::'s
(Name of Property Owner)
property lomted at /2 2 �• �L wooer C .�v�2 7—
(Lot, Block, Road, etc.)
on ��lJ..��/�/!J , in �i'Z9 t/�L! (_csa uNT�/ N.C.
(Waterbody) (Town and/or County)
He has descnlW to me as shown below, the development he is proposing at that location,
and, I have no objections to his proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMEW
(To be f filled in by individual proposing development)
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Signature
✓orr A —I C 00�e &
�rict�r.� J. /��o,e�•
Print or Type Name
zoo 9278
Telephone Number
Date: