General Permits (4280)

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CERTIFICATION OF EXEMPTION
_Y 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
Address
City
Project Location (County, State Road, Water Body, etc.)
Type and Dimensions of Project
Phone Number
State
Zip &�—
The proposed project to be located and constructed as described This certification of exemption from requiring a CAMA permit is
above is hereby certified as exempt from the CAMA permit re- valid for 90 days from the date of issuance. Following expiration,
quirement pursuant to 15 NCAC 7K .0203. This exemption to a re-examination of the project and project site may be necessary
CAMA permit requirements does not alleviate the necessity of to continue this certification.
your obtaining any other State, Federal, or Local authorization.
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.
CAMA Official's signature
Issuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

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ID719197282092 PAGE 3/3
JUN-30-95 15:19 FROM:
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I hereby
CENTRAL. PERM rT OFFICE OF
C0UFRTH¢U5E SQUAB£
BEAUFORT. N. C. 28516-1898
72S-S! 45
BIL�tO�PYGS_ rM06=1L8 ?g0FAE& EL£CTMCAI_ PLUMFW"G_ MECKAMCAL
AD,TAO °t RIPARIAN PROPERTY OWNER STATEMENT
;tiffy that ZIown property adjacent tO:
property 10cated at:
near (water body)
in (Conant-y) � r
The applicant described to me as shown beloca f the development
he/she is proposing in that location and:
I have no objections to this proposal
I do have objectionS 'tQ this proposal
Description and/or drawing Of proposed development:
Signature
.
Name:
Phone Number: