General Permits (4250)

ILL
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CERTIFICATION OF EXEMPTI APR"`' 1991
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 1-5-NOAC Subchapter 7K :0203:
Applicant Name k ':> k-e-' �_, - : �, ��-_ Phone Number
Address is 1M'.
City ^yy 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 t5 NCAC 7.K :0203'. This exemption to
CAMA permit requirements does not alleviate the necessity of
your obtaining any other State, Federal, or Local authorization.
SKETCH
�i
i
Any person wnu proceeus wars a uevesuNrI sern WRI IMUL uic wn-
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.
This certification of exemption from requiring a CAMA permit is
valid for90 days from the date of issuance. Following expiration,
a re-examination of the project and project site may be necessary
to continue this certification.
N
(SCALE: )
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1
a
Applicant's signature
CAMA Official's signature
\C1�'
Issuing date
Expiration date
Anaciiment: 15 North Carolina Administrative -Code 7K .0203