General Permits (4913)

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Applicant Name
Address J,)
City h
Project Location
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CERTIFICATION OF EXEMP �s . ;i.
FROM REQUIRING A CAMA PERMIT JUN 2 1992 E
as authorized by the State of North Carolina, (�
Department of Environment, Health, and Natural Resources and the Coastall Rw�.91JLQP
in an area of environmental concern pursuant to 15 NCAC Subchapter 7K .0203.
i !��f Flc�;,Pia��rt ! Phone Numbers
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Type and Dimensions of Project
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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.
State
zip 2 " I_S
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:
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Any person wno proceeas witn a aeveiopment wiinout ine wn-
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
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Issuing date
` 2- 3/CIZ
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203