General Permits (4221)

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CERTIFICATION OF EXEMP
FROM REQUIRING A CAMA PERMIT 1: Aua U V W- ;i I
as authorized by the State of North Carolina,1 11
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Department of Environment, Health, and Natural Resources and the Coasta a o+ s�o
in an area of environmental concern pursuant to 15 NCAC Subchapter 7K .tomesee 6""~'480
Applicant Name a k rbe
Address
City
Project Location (County, StaV Road, Water Body, etc.)
Type and Difnensions of Project,, &i1, &;
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.
Phone Number 2 /
State ,'I - 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.
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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.
i
pL
Applicant's signaure
CAMA O icia's signature
Issuing date
Expirationr8ate
/V.A.,_004
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Attachment: 15 North Carolina Administrative Code 7K .0203