General Permits (5596)

O
Applicant Name
Address
City
CERTIFICATION OF EXEMPT
FROM REQUIRING A CAMA PERMIT1�
as authorized by the State of North Carolina,
Department of Environment, Health, and Natural Resources and the CoastalTI1rY1115Z5151
in an
area of environmental concern pursuant to 15 NCAC Subchapter 7K .0203.
r—rre N � E fP V•� Phone Number J5I&
Pro ect Location (County, State Road, Water Body,
Type and Dimensions of Project -Doc 4—
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.
State
Zip 11 jam''
This c(,rtification 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 N -,- - . ,, I i j (SCALE: Jb't i i, )-I
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-writte;�-statementbaste�en-obtained-from-adjacent
landowners--eertifiyttrg�th'ttte e-•no--objections-to--the
p rspesed-wee ,.— ly _""r C
4'
VD
PIS
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signature
(11
CAMA Ojf ial's ignature
Issuing da
?C7N
Expiration date
P�_
C17196�'
Attachment: 15 North Carolina Administrative Code 7K .0203