General Permits (4503)

CERTIFICATION 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-NGAC Subchaptex7K :02D3."
Applicant Name Phone Number IA-) a 0
Address
City, .. State Zip V, i U
Project Location (County State Road, Water Body, etc.).
Type and Dimensions of Project_
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-74<-.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.
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sent of a CAMA official under t a to tlb r that the
development is exempted, will b violation of the CAMA if t
is a subsequent determination t a l:M v9sieq i for
development. j
The applicant certifies by signirM"!k VfftPtie1MhM"!
plicant has read and will abideFllJRRi�l�
tion, and (2) a written statement has been obtained from adjacent
landowners certifying that they have no' objections to the
proposed work.
Applicant's Vturt e
CAMAOfficial's signaturet6 `— t
Issuing date
Expiration date
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