General Permits (4815)

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CERTIFICATION OF EXEMPTION
FROM REQUIRING A CAMA PERMIT
as authorized by the State of North Carolina,
Department of Natural Resources and Community Development and the Coastal Resources Commission
in an area of environmental concern pursuant to 15 NCAC Subchapter 7K .0203.
Applicant Name Phone Number
Address
City State Zip
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 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 60 days from the date of issuance. Following expiration,
a re-examination of the project and project site may be necessary
to continue this certification.
Any person who proceeds with a development without the con-
sent of a CAMA official under the mistaken assumption that the Applicant's signature
development is exempted, will be in violation of the CAMA if there
is a subsequent determination that a permit was required for the
development. CAMA Official's signature
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.
Issuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

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IF
THE TOWN OF PINE KNOLL SHORES
TELEPHONE [phone]
PERMIT APPLICATION
(SMALL PROJECTS, REPAIRS AND REPLACEMENT)
MUNICIPAL CIRCLE
PINE KNOLL SHORES, N.C. 28557
DATE to / a-r / /
NAME PHONE#�3
ADDRESS 7 '�' /V �L�('�-iJ' 1 G" /I J d-, /'l/ C ,
JOB SITE ADDRESS
STREET ADDRESS14At. C?•'Lv' f I74 c: � /�,
LOT # 3 BLOCK A111 PARCEL#
CONTRACTOR INFOMATION
NAME
ADDRESS PHONE#
LICENSE(IF REQUIRED) #
PINE KNOLL SHORES PRIVILEGE LICENSE YES ( ) NO ( )
DESCRIPTION OF PROJECT
ESTIMATED COST IoZb .a SIGNATURE z/
(PERMIT REQUIRMENTS)
(1) ALL PERSONNEL DOING WOPt,,,i� IN PINE KNOLL MUST HAVE A VALID PRIVILEGE
LICENSE.
(2) ALL WORK MUST BE DONE BY LICENSED PERSONNEL WHEN REQUIRED BY STATE
CODE.
(3) ALL PROJECTS MUST BE SUBMITTED WITH DRAWING AND PLOT PLANS,EXCEPT
REPLACEMENT OF ELECTRICAL,PLUMBING OR H.V.A.C. EQUIPMENT.
(4) ALL OUTSIDE CONSTRUCTION MUST BE APPROVED BY LETTER FROM THE APPLICABLE
HOMEOWNERS ASSOCIATION.