General Permits (3507)

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CCERTIFICATION OF EXEMPTION Id
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 Phone Number
Address
City State Zip
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.
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.
development is exempted, will be in violation of the CAMA if there
is a subsequent determination that a permit was required for the
development. CAMA Official's signature
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.
Issuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

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PAMLICO COUNTY BUILDING INSPECTIONS
P.O. BOX 776
BAYBORO, NC 28515
(919) 745 -3861
ADJACENT RIPARIAN PROPERTY OWNERS STATEMENT EPN#
I HEREBY CERTIFY THAT I OWN PROPERTY ADJACENT TO ANN R. GWALTNEY
NAME OF LANDOWNER PROPOSING DEVELOPMENT
ON GREENS CREEK NEAR ORIENTAL LOT # 13 OF GOOD WINDS
BODY OF WATER SUBDIVISION, IF APPLICABLE
TAX PARCEL # I092-19-13 OFF SR 1308
COMPLETE DESCRIPTION OF HOW TO LOCATE THIS PROPERTY. GOOD WINDS
SUBDIVISION OFF SR 1308 NEAR ORIENTAL
THIS PROPOSED PROJECT IS A 128' RETAINING WALL PLUS RETURNS AND I HAVE NO OBJECTIONS
TO THE PROPOSAL.
After this form is completed by the landowner proposing the project, a copy is given to the adjacent landowners for their
consent and signature. The forms are then returned, along with a building plan and other applicable required information;
to the building inspection office for building permit application/processing.
SIGNATUREA�-'tl- �'L DATE `S 2)

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PAMLICO COUNTY BUILDING INSPECTIONS
P.O. BOX 776
BAYBORO, NC 28515
(919) 745 -3861
ADJACENT RIPARIAN PROPERTY OWNERS STATEMENT EPN#
I HEREBY CERTIFY THAT I OWN PROPERTY ADJACENT TO ANN R. GWALTNEY
NAME OF LANDOWNER PROPOSING DEVELOPMENT
ON GREENS CREEK NEAR ORIENTAL LOT # 13 OF GOOD WINDS
BODY OF WATER SUBDIVISION, IF APPLICABLE
TAX PARCEL # I092-19-13 OFF SR 1308
COMPLETE DESCRIPTION OF HOW TO LOCATE THIS PROPERTY. GOOD WINDS
SUBDIVISION OFF SR 1308 NEAR ORIENTAL
THIS PROPOSED PROJECT IS A 128' RETAINING WALL PLUS RETURNS AND I HAVE NO OBJECTIONS
TO THE PROPOSAL.
After this form is completed by the landowner proposing the project, a copy is given to the adjacent landowners for their
consent and signature. The forms are then returned, along with a building plan and other applicable required information,
to the building inspection office for building permit application/processing.
SIGNATURE DATE