General Permits (4495)

CERTIFICATION OF EXEMPTION
FROM REQUIRING A CAMA PERMIT
as authorized by the State of North Carolina,
el
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 Rg Phone Number 2201— % d S Ll7��
Address I a 4;" 1 S 4`
City JA 1 , State 14/f zip
project Location ounty, State Road, Water Body, etc.)
Type and Dimensions of Project 4/2
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 .0203. 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: )
f de
"Y
o
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.
� ltp Apli an�gnature�
Ap!
,1
CAMA Official's signaftire
Issuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

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r ,-k0JACF F J111AjR [;A N mopmrry UwNER STATMLTri`a'
r (FUR A PIER!M{JfIJ{ING 1'IL1NCr ILt0�1TLIFrlAC?A%'1%itJSl;�
herchy ecrtify Thal I c�w,� property adjarc:nt to je2-_�,
' (Name of Property Owner)
(Lot, Block, Randp etc.) ----.__
on(*a+terbady) (Town xudlar roaAty)
Nc ha9 4ewflSad to ma. no shown below, the development Sze is proppRing 0 that
location, and, i have no objccti(ins to hk proposal. l undermand that a rierlmooring
piiin�sl�aatliilit�aalhou mt:�t be se! back a minlmunndlstance of Veen feet(l5") from +ay wci i
of riparian Access unless waived by me.
I do Oat wish tip U,;m 0 the settmQk requirement,
_ I da wish to waive mat selbaek requirement,
(To he filled to by lnd1vidoal proposiAl 6volopmenr)
- --- - - ............... .. ---------------------
Print ter I'Ypc. Name
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