General Permits (5229)

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PERT-IFI�ATION OF EX 4
FROM REQUIRING A CAMA PERMIT
as authorized by the State of North Carolina, sand the Coastal Resourcgs Commission
Resources
Department of Environment, Health, and Natural Reso -
.. in an area of environmental concern pursuant to 15 NCAC Subchapter 7K .0203.
Number
Phone
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Applicant Na
Address Zip
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City L
Viect Location ( unty, State Road, Wat Body, etc.
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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.
SKETCH
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) awritten statement has been obtained from adjacent
landowners certifying that they have no objections to the
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:
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Applicant's signaure
1 • r
CAMA official s signature
Issuing date / t
Expiration date
Code 7K .0203