General Permits (4319)

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CERTIFICATION OF EXEMPTI FES 2 991
FROM REQUIRING A CAMA PERMIT
as authorized by the State of North Carolina,
Department of Environment, Health, and Natural Resources and the Coastal
in an area of environmental concern pursuant to_15 NGAC -Subchapter 7K- 0203.
Applicant Name /c, %t Phone Number
Address°
City 'ir..r .f, r. State Svc' Zip
Project Location (County, State Road, Water Body, etc.)
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Type and Dimensions of Project i
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-.A203. This exemption to
CAMA permit requirements does not alleviate the necessity of
your obtaining any other State, Federal, or Local authorization.
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.
SKETCH (SCALE: )
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.
Applicant's signature
L� rl -�
Cf icial's signature i J
Issuing date
Expiration date
Attachment:.15 North -Carolina -Administrative Code_7K .0203