General Permits (4885)

0 CERTIFICATION OF EXEMPTION
FROM REQUIRING A CAMA PERMIT e-
as authorized by the State of North Carolina, g du� 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 Phone Number (o
Address
City - ", i�' % t State ! zip " S '
Project Location (County, State Read, Water Body, etc.)
Type and Dimensions o Project
1 L
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 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.
I 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.
r..
al's sianatun
Issuing date
-/
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

` ADJACENT
RIPARIAN PROPERTY CUNER
STATE UMn
II hereby certify that I own property adjacent to
`s property located at
(Name of Property.
Owner)
(Lot, Block, Road, etc.)
on l� Ec�S h V�
in %� �� N.C.
(Waterbody)
(Town ands/or County)
He'has described to
as shown below, the development he is
proposing at that location, and; I have no objections to his
proposal.
`DESCRIPTION' -'AND/OR
DRAWING OF PROPOSED DEVELOPMENT:
(To'be filled in
by individual proposing development)
Ic IT
/U
ignature
S:t ate t� f
Print or Type Name
Telephone Number
No are• Puhl i c
r
'My:'=`'einYosuri Expires:

'78> Fa 4-- Ti
ADJACENT RIPARIAN PROPERTY CUNER STATEMENT
I her certify that I own property adjacent
to
's property located at
Property. owner
(Lot, Block, Road, etc.)
;.
�cz ' S.h �� �n in%�ew !� ��Tr� N.C.
(Waterbody) (Town and -'/or County)
;He.,has'described tome, as shown below, the development he is
proposing at that location. —and; I have no objections to. his
proposal.
DESCRIPTION AND/OR'DRAWING OF PROPOSED DEVELOPMENT:
(Toy be filled in by individual . proposing development)
County of
State of��«��+ J
Notary Public
Si�ate /
Print or Type Name
elephone Number

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