General Permits (4485)

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CERTIFICATION OF EXEMPTION
_Y FROM REQUIRING A CAMA PERMIT ,,p
as authorized by the State of North Carolina, l
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 f, 'j ' �� o "� L� Phone Number '1
Address " b`J
City Vt11 State i C zip
Project Logation (Co nty, State Roac Water Body, etc.) . e, It Y ! I � f• � ,
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Type and pimensions of Project - ^ ,) "^ ' I ,- r ` •�' -2 3 9 3L -4 b ' bs-
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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: )
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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.
1
App'cant's �jgnature
(I
CAMA Official's signature
it
Issuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

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I Cha>; es A. Rawls, a Registered Land Surveyor v
dqw �`rte,� ,,.certify that the physical features as O
„��.• ;g��is:�,i.•t1 h, are based on an actual survey made Q
"'': •' ,;.% �� d'�t`�Itvy�� t�#Ft supervision. Elevations shown a
M veLd � rt}ean sea level datum. -
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