General Permits (4923)

CERTIFICATION OF EXEMPTION JJ `,ram,
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
in an area of envirionmental concern pursuant to 15 NCAC Subchapter 7K .0203.
Applicant Name
Address '//10/1
City
Project location (C unty, _State
Type and Dimensions of Project
r Body, etc.)
Phone
State AfI(f '
The proposed project to be located and constructed as described This certification of exemption from requiring a CAMA permit is
above is hereby certified as exempt from the CAMA permit re- valid for 90 days from the date of issuance. Following expiration,
quirement pursuant to 15 NCAC 7K .0203. This exemption to a re-examination of the project and project site may be necessary
CAMA permit requirements does not alleviate the necessity of to continue this certification.
your obtaining any other State, Federal, or Local authorization.
SKETCH (SCALE: )
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may-
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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
velopment.
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 Officers signature
Issuing..date1, 1 I ., 140zeo9l Z
-
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

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ADJACENT RIPARIAN PROPERTY OWNER STATEKENT
I hereby certify that I own property adjacent to
� Y)\—, S L-Pi" 11 N �, , f=) t ' �'> Is property located at
(Name of Property owner) } Sc v n} �ri'v 1`31L,A 3L
(Lot, Block, Road, etc.) on �OF u-u � �c;� �� in 1�,va1)�� , , N.C.
(W erbody) (Town and/or County)
He has described to me, 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)
4
S ' gna ture
Print or Type N
Telephone Number

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to
4 TN),s t,i,11)'8), LJJ}; 's property located at
Name of Property Owner)
l 1o(o J0vy\� )Oc1t 3 ,
C (Lot, Block, Road, etc.)
on J0c-yx) , in %y,�va�� :.Ls),. N.C.
(W erbody) (Town and/or County)
He has described to me, 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)
1Ar'
Sig ature
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Print or Type Name
Telephone Number