General Permits (4682)

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Applicant Name
Address, _✓
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
ira an area of environmental concern pursuant to 15 NCAC Subchapter 7K .0203.
L Phone Number
City ' .1 r4':
Protect Location (County, State Road, Water Body, etc.)
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Type and Dimenstn$/ of Project on1-ir
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proposetl project to be located aAPcolAtruct d ?s1d'els1cribeda'
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.
State A/Zip 01 -6 .t/
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This crtificatio 04 exemption from requiring a CApermit 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: AJ,- ' -A ''5,, tC )
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',§,sigPature -
( i ( �-
CAMA Off ic ' s`sig ture
Issuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203
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