General Permits (3109)

Applicant Name
Address P
City
Project Location
CERTIFICATION OF EXEMPTION 9
FROM REQUIRING A CAMA PERMIT (oJ
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.
C>uSepl, i 41_1�1b'rel Phone Number �'17 7' '
moy
county, lState
Type and Dimensions of Project
ad, Water Body, etc.)
a .-�• ._3-Ki ,'lam te.
ct
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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State A.41 Zip
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3
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.
j SKETCH (SCALE: %J/;L)„ ) j
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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.
Appucant•s signature
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CAMA Official's signature
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Issuing date
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Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

CENTRAL PERMIT OFFICE OF
Q 1 MEARM V Ge CULZNTYV
CCURT}10USC SQUARt
SCAUfCRT. N. C 2831 15-1 a9a
72a•a343
SUILOINGI. WOSILC "CUM CLCCTMKwI *4CCNAMSC AL
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I here certify that I own property adjacent to:
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property located at: " {
near (water body) 641na&
in (county).
The applicant descri.bed to me as shcwr below, the development
he/she is proposing in that location and:
I have no objecticns to this proccsal
I do have objections to this prcccsal
Description and/or drawing of proposed development:
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SiCna�u:e:
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Phone Numtler : J?O,�'_ /0 l
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CENTRAL PERMIT OFFICE OF
00
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COURTHOUSE SCUARt
9£AUFCRT. N. C. 2a3 i a. i afla
72a-a3AS
GUILDINCIL A409P C "C"c3. CICCTRKAL ►lu►464HC, WC04AM<AI
ADJACENT RIPARIAN PROPERTY CWUZR STATEMENT
I hereby �,,!
rti:y that I awn property adjacent to:
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property located at:
near (water bcdv)
in (county).
The applicant described to me as shown below, t.ie development
he/she is propcsing in that location and:
I have no objectons tiothis proccsa_
I do have objections to th-;-, pr^cosal
Description and/or drawing oz proposed development:
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Signat
dame : Ji1�.<s Ff�Z.�-3eTry %?1 ✓vM� /5�:_
Phone Number: