General Permits (4666)

N
CERTIFICATION OF EXEMPTION
FROM REQUIRING A CAMA PERMIT A*
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
Address
City
Project Location (County, State Road, Water Body, etc.)
Type and Dimensions of Project
State
Phone Number
Zip
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. (j _
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
CAMA Official's signature
r
Issuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

JAN-S2-99 TUE 02:19 PM LORA M BYRD
FAX:[phone] PAGE 3
ADJACEW I AMAN PROPERTY 0WNI,__;STA
I hey certify that I own property adjacent to _ v r H KOR. 2
- (Warne r,P Property Owner)
ProperiY
- lat.) Block, Road, etc.)
on 060EF 3ouN7 in Of Poo--C, N.C.
(WaLerbody) (Town ani/or Coumtp)
Iqe has described to rne.as shown below, the developwent he is proposing at that 16ci. ony
aic7•, i have no objections to hL- prop- 13 rl.
p: • I;FFESCItIMO _F VDIOR DRAWING OF F`-' .' 57M DFVE FS_"=;'N
t' (To be fiUed &r by individual Pr .ipvn,::e ; fs Pment)
• U' 3149 P
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JAN 2 6 1999
Sisnawre
Print or Type Name
Televhone Number
Date:
01/12/99 15:22 TX/RX N0.0164 P.003

JAN-ti'.2-99 TUE 02:19 PM LOAA M BYAD
FAX:[phone] PAGE 4
ADJACENT '- _/PARJAN PROPMTY OWN,._:Z STATEMENT
I hereby certify that I owa property adjacent to oeu- tt 's
(Name of Property Owner)
property located at [ �-�
(Let, BllocI4 Road, etr—)
on ty�u-�AUNt7 in %J
N-�---
(Waterbody) (Town. andlor County)
He has described to mem .shown Qelaw, the development he is proposing at fiat ?6cn y
and; I have no objections to his prupci-Z.
DESCREMQ .- u/0R DRA NVG OF PROPOSED DEVELO
(To be f'ed i:: by individual proposing deve%pmgnt) =
JAN 2 6 1999
v = ei/` 5 per_ r .34q I
,.elA
/I z
Si�aature /
Er Z-L.��1 '�;. d m -Tc7'-
Pant or Type Flame
Zc13-7a-1k
Telephone Alumbe:
01/12/99 15:22 TX/RX N0.0164 P.004