General Permits (4875)

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Applicant Name _
Address
City
Project Locatipn (
CERTIFICATION OF
FROM REQUIRING A LAMA PE T - � .I� s,'
as authorized by the State of North Carolina, LriLJ
Department of Environment, Health, and Natural Resourccsaud2be_CoastaLl3.P_ ��..9s Commission
in an area of environmental
concerns pursuant to 1*NCAC Subchapter 7K .0203.
G JdL ca "�� � /Z� c Q��' .�PC_0 'S Phone Number
State Road, Water Body, etc.)
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Type and Dimensionp 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:"9VCAC 7K .0203. This exemption to
CAMA permit requirements does not alleviate the necessity of
your obtaining any other State, Federal, or Local authorization.
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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: ! )
I
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 signs
IA Off iciall'�'s�� s
=-f
ng date ,
Expiration date
Attachment: 15!horth Carolina Administrative Code 7K .0203