General Permits (1807)

y CERTIFICATION OF EXEMPTION
FROM REQUIRING A CAMA PERMIT t
• as authorized by the State of North Carolina,
Department of Environment, Health, and Natural Resources and the Coastal Resourc s mission
in an area of environmental concern pursuant to 15 NCAC Subchapter 7K .0203.
Applicant Name _o ' Phone Number f// "'-
Address t t i
City r - ^ !' State /iiC Zip S /
Project Location (County, State Road, Water Body, etc.) 12A -: T-0 o C U t1'
tip i�c � _y f� _�' ;�� ;i � %�� r'iv�— Sc�ci � � /�i�-_n � < r rn-
Type and Dimensions of Project Li0 h-�f '1i k L
�r�ST��f w l f, y i (r h✓
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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 f L (SCALE: )
���RZZWZAE_
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.
We 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.
PAR
Applicant's signature
CAMA Official's signature
Issuing date
1 7
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
hereby certify t;iat I own property adjacent to
's property located at
(Name of Property Owner)
rzz"'� - r
4
D,
(Lot, B1 k, Road, etc_)
v
on in N.C.
(Waterbody) (Town /or unty)
He has described 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 DEVELOPMENT:
(To be filled in by individual proposing development)
Sidnatur
Print or Type Name
i1�7 77 'c4 1.3
Telephone Number
9

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to
is property located at
(Name of Property Owner)
(Lot, Block, Road, etc.)
on �, /� in N.C.
(Waterbody) (Town d/or County)
He has described 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 DEVELOPMENT:
(To be filled in by individual proposing development)
Si nature
Print or Type Name
Telephone Number
9

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