General Permits (2195)

CERTIFICATION OF EXEMPTION p
FROM REQUIRING A CAMA PERMIT
as authorized by the State of North Carolina, Po C %1
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 me �_.� u , ✓ �' / / +
Address 1060 4l
City r �"
Project Location (County, State Road, Water Body, etc.) -, o
State
Phone Number i r ' ) dK � / Sir
Type and Dimensions of Project Al"
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.
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.
I SKETCH (SCALE: )
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
sevelopment.
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's' nAture
4J)
CAMA Official's signature
Issuing date
� (; _y t,
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

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ADJACEN
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I �e'�hy oratfv that 1 owl, t!'�R�e t�f �t'ttg�sty er)
Block; Road, [etc.)
e- ....•-_.a..,.r.,..°
On
(T6wn andi or County)
twatet�bucl�)
4' has (: 5Cf1�3C+::f� &:ve S7�1men% he ii pft^^�46'.Di 4�i t?,At !%a' Orin
ICE `I�N A*,,M/OR DR.� WING OF iriiL�'�JSE:D La����lt3r'i`►�F.'Ki
('o be,Ut^ fir, v individual d-vmi-49 d*v*IOPmcert)
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I hereby certify that I own property adjacent tro Or- (operty s
properly locatc'd at _1='` _r �'� �s--�%' �L w_ SJ�r✓�� j�;�T�
(Lot, Block, Road, etc.)
in ���w'7�Z� s'G:l� _
(Walerbody)'-- - - - - (Town and{or County)
He has described to me a, Down below, the development he is pz(,posing at that location,
and, 1 have no objections to his proposal.
DESCRIPTION AND/0k DRANVLVG 01" PROPOSED DEVEY.,()PMEN71
(To be filled in by individual pn)po ing development)
. _gnatu _- - - ----
Print or Type Name
r.lepha�2c Number
----- - - - - --

ADJACENTRIPARlAN PROVERTYOWNER STATEMENrr
2
e�Cr��?b y$fi�'4' t",ri(! il:l'Si �iii�st�"'� C`�L'�Fl�iviil ��� �����d
(fAT Block, Road.
tT.,-jwu an(Vor Coantyj
H� has tgincrlbek, V, ?no A" pmelj t;e is pq%poslng at that location,
an,j, ! !;o �o "Its PrOjAOS"A:�
Ok-SCRIPTION ANDI'OR DRA'vA LNG (_';f MOKJSM I)EVELOPMM'
,Tt) be oLofj irl h,v propvsing dovtlopmenl)
............
Signature
Print or Tylx NcTle

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