General Permits (2917)

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 15 NCAC Subchapter 7K .0203.
Applicant Name
Address
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 Number
State
zip S
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 (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
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
Issuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

11I28?2007 09:14 2789558 PUBLICWORKS PAGE 02
ty'11;-Z7-c0137 1E.:49 From: 7o:270c)558 G.a-a
3
�r CERTIFICATION OF EXEMPTION
rROM REQUIRING A LAMA PERMIT
os authorizad by the stale of Nonll comllna,
ospartmaaru of Cnvironment. HOAIth, and Natufw Rooaurcas and tho Ooowal Mosaur000 Oomrelesbw
In nn area of onvirdnmorttai concorn pursuant to 15 NCAC Subenapror 7K 0203.
Applipz d Name—1"L�+t.gY ix iF- &3J%X
Address _19a1 jic,_L�lk tL,. l �..L1 tadtQ__ cY�L.rs
city
Pried �ocafion (County. State load, W$ter Bally, 41C.)
Phor* Number s l : Wj
state �_ zip
Type and Dimensions of Prolect (a._._i��.l►a+Yr 1t11�'« -- -
71,o praposod proleat to be locatod and aonefn,ctod an doocrit�od
otovo is horaby oortif od Re exempt tram 1ho LAMA permit ra-
gwromont pursuant to 15 NCAC yK •02W, Thle exemption to
CAVA patmii roqulrortianta ttgoa not altavlata the naa000Ny Of
your abraminp any other Siate, Fodor*), pr LoRa) authorization.
Tt)la canifiaation of oxom¢tlon from requl+lnp a CAMA por-" s
valid for 50 days from tho data of lacunnoo Fo1owfnp oxplration,
a ro-010minef ion of the pralect and projrat she may be nsaseeary
to Cortinue this csrtiflCAtbn.
r841CH (SCALE:--- -- ) j
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Any parson who proaaada whh c dsvolopmntn without the OW
MY pl a LAMA otfieiol undor ins mislakort aswmption that ;hs
dovoloprriart Is oxompted, will be In vloloaon of the CAMA If thora
is p tu�apquent daterminaltonthfit a pbrm" woe requlrod to►tho
devvlopm ont.
Tr,,e ,applicant osrtttlav by elgnhq this oiamptbn that (1) the op-
phcarrt hat rood and wtlablde by tha oanditaas of this oxomp-
unn, rnd (2) a twr"Ien atal.emont hac twos obtalnad from POW'
lancownoro oortiryiny thou ft+4y have no obiect-10 TO the
propocod WON.
a
if I/off - .. , —
Ia K+y d �
01-IZ7)--
t:><pi'Duon date
Attachmont: 16 North Carolina Adrnlnisrreftw Cede 7K 0203