General Permits (4018)

9
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 Phone Number 9/1) y3-y U5�
Address ♦ UU
City State zip
Project Location (County, State Road, Wat r Body, etc) 0 -f
A - R
Type and Dimensions of Project L r, rMne
The proposed project to be located and constructed as described
This certification of exemption fr
for 90 days from the date i
r irij� �AMf 1p rt i
owing bxpir
above is hereby certified as exempt from the CAMA permit re-
valid of
ance. of
quirement pursuant to 15 NCAC 7K .0203. This exemption to
a re-examination of the project an
jec sita rr}y�eygtssa
JJ UU UU !!
CAMA permit requirements does not alleviate the necessity of
to continue this certification.
your obtaining any other State, Federal, or Local authorization.,
SKETCH- r (SCALE: )
n
-bock_
W
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.
1 c0' a_�i & A
T�cic� mold
sign%0re
nature
as
Issuing date G
i
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203