General Permits (3064)

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Applicant Name
Address
City
Project L,Qcatior
tfCERTIFICATION OF EXEMP F1^
FEE o
rROM REQUIRING A CAMA PERMIT
as authorized by the State of North Carolina,` G
Department of Environment, Health, and Natural Resources and the Coast4Resources Commmi io" ►"W-
in an area of environmental concern pursuant to 15 NCAC Subchapter 7K .0203.
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be,(b State
State Road, W er Body, etc.)// I
Type and Dimen %ions f Project 00 D'
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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.
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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.
Phone Number? 7
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.
(SCALE: /.
110
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Applicant's signatur
CAMA Official's signature
Issuing date
l- -9
Expiration date
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