General Permits (1811)

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Applicant Name
Address �7 "
City
Project Location
CERTIFICATION OF EXEMPTION t" ' ,
FROM REQUIRING A CAMA PERMIT �,�,., •j-.�pv-,
as authorized by the State of North Carolina, 1
Department of Environment, Health, and Natural Resources and t eA0al Resources Commission
in an area of environmental concern pursuant to 15 NCAC Subchapter 7K .020$ r�; ry
unty, State Road, Water Body, etc.)
State
Phone Number �/ 2 i 3 r 2 Y�
Zip r`
Type and Dimensions of Project !' -7 Ue f ,^ , ; � 1, < r' L- ;;, 6
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.
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.
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.
Applicant's signature
CAMA Official's signature
Issuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

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ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
hereby certify that I own property adjacent to
's property located at
Nam of Property
o (Lot, Block, Road, etc.)
on �`� , in Isea C N.C.
(Waterbody) (Town a 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)
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log
Signature
1?4 C le
s�oc__ Print or Type Name
Telephone Number
19-1

ADJACENT RIPARIAN LANDOWNERS STATEMENT
General Statute 113-229 requires that riparian landowners
with property adjoining a proposed excavation and/or fill project
be given thirty (30) days in which to comment on the project.
This form allows the adjacent riparian landowner to express
either: (1) That he objects to the project; or, (2) That he does
not object and desires to waive his right to the 30-day period so
that the processing of the application can progress more rapidly.
of course, the adjacent riparian landowner need not sign this
form at all if he so chooses.
am an adjacent
riparian property owner and have seen a copy of the application
submitted by , dated
, 19 , wherein said applicant requests a
permit to excavate, fill, or otherwise alter the land or water
adjacent to my property.
l/ I have no objection to the project as presently proposed
and hereby waive that right of objection as provided in
General Statute 113-229.
I'have objections to the project as presently proposed
and comments are attached.
nature Adjacent
Riparian Landowner
DATE: �� 9
FORWARD COMMENTS TO:
Division of Coastal Management
P. O. Box 27687
Raleigh, NC 27611