General Permits (5124)

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-� CERTIFICATION OF EXEMPTION
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 are(a� of environmental concern pursuant to
Applicant Name Phone Number 1� -Sy
.Address t b V� S V,
City State Zip ;
Projecocation CCounty, State Rpad, Water Body, etc.j� u C4. t
Type and Dimensions
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 for9W=L-W from the date of issuance. Following expiration,
quirement pursuant to This exemption to a re-examination of the project and project site may be necessary
CAMA pefmit requirements does not alleviate the necessity of to continue this certification.
your obtaining any other State, Federal, or Local authorization.
SKETCH (SCALE: W N C )
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+ate Jiz�� SiD•1
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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
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.
Appucant's signature
CAMA Official's signature
1i - 1,C�
Issuing date
Expiration date
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