General Permits (5112)

-v
CERTIFICATION OF EXEMPTIONv '
FROM REQUIRING A CAMA PERMIT �o�
as authorized by the State of North Carolina,
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
Address
City
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.
Phone Number
State Zip
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: )
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 signature
CAMA Official's signature
Issuing date
ri I F7
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

Permit tee Is NamePP�ermit #
Location: — V Field Rep
Phone: Date of Report:
Description of Proj ect :�
Date Project Reportedly Ccmp-nte: I
(1) Do the measured dimensions of the developm iffer from those
indicated in the permit .and rkplat? Yes / No Have all permit
conditions been satisfied? Yes / No
COMMENT:
(2) Sedimentation and Erosion Control: Has permi �ee seeded, grassed,
or otherwise stabilized all disturbed areas: Yes No
COMMENT:
(3) Future Monitcrina and Znforcement Act' Is`further investigation
or enforcement action needed? Yes / Nb
COMMENT:
0

Permitt e's Name
� �
Y20
Location:
Phone:
Description of Project:
Date Project Reportedly Compnte:
Permit #�� —y
Field Rep.
Date of Report:
(1)' Do the measured dimensions of the develodiffer from those
indicated in the permit .and rkplat? Yes / No Have all permit
conditions been satisfied? Yes / No
COMMENT:
(2) Sedimentation and Erosion Control: Has permit-- seeded, grassed,
or otherwise stabilized all disturbed areas: es / No
COMMENT:
(3) Future Monitoring and F6nforce
or enforcement action needed?
COMMENT:
nt Acrtig
Yes / o
Is'further investigation