General Permits (5212)

-Y
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
i in an area of environmental concern pursuant to 15 NCAC Subchapter 7K .0203.
Applicant Name A 0
Phone Number
Address /44 ,.i —
I Ci
City State Zip aQ'r/ a
j Project Location Co nt , St to 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.
SKETCH
t
s
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 CAMA4 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.
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.
(SCALE: A� )
Applzaffs sigg6a e
/ /J n SS s-%%—
CAMA'Official's signatufd
9-rl-y�
Issuing date —7
/7
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203