General Permits (3407)

Applicant Name _
Address �
City
Project Location
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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:NCACSub..chapter;.7.t<- 0203..,
Road, Water Body, t
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 1'5=NGAG 7K.-0203.. This exemption to
CAMA permit requirements does not alleviate the necessity of
your obtaining any other State, Federal, or Local authorization.
ate
Phone Number ;:)� X"Vi =�A�AtA
Zip a-YM O
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.
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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.
App cant's sCiatu re
CAMA Official's signature
Issuing date
Expiration date
Attachment.-x1stClC� trde 7K .0203