General Permits (4286)

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CERTIFICATION
-� C CATION 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
Address
City
Project Location (County, State Road, Water Body, etc.)
Type and Dimensions of Project
State
Zip i
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.
SKETCH (SCALE: )
t
Any person who proceeds with a development without the con-
sent of a CAMA official under the mistaken assumption that the Applicant's signature'
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 Expiration date
proposed work. i
Attachment: 15 North Carolina Administrative Code 7K .0203
1

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POBOX 776 --1Vfthd9*-COUNTY BUILDING INSPECTIONS BAYBORO, N.C. 28515
[phone]
(After this form is completed by the landowner proposing the project,
a copy is given to his/her adjacent landowners for their consent and
signatures. the forms are then returned, along with a building plan
and other applicable required information, to the Building inspections'
Office for building permit application/processing.)
ADJACENT RIPARIAN PROPERTY OWNED: STATEMENT EPN#
I hereby certify that. 1 own property adjacent to
/U cT S Is on
Name of landowner roposing development body //of water
in/near �1�� /3er Lot�P of
community Subdivisio , if applicable
e off SR Complete description of how to
locate this property:
The proposed project, a ✓ f� ✓ , and the location has been
described to me as shown in the drawing below and I have no objections
to the proposal.
FOR A PIER, CHECK ONE OF THE FOLLOWING:
Iw"sh to waive the 15, minimum setback from my riparian access.
VI DO NOT wish to waive t ' he 15 minimum setback requirement.
Draw the proposed structure in the space provided below. List the size
of the structure and measured distances from the adjacent property
lines, other structures on the property, and the road, water, etc.
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