General Permits (5670)

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CERTIFICATION OF EXEMPTIO
FROM REQUIRING A CAMA PERMIT
as authorized by the State of North Carolina,
Department of Environment, Health, and Natural Resources and the Coastal Reso
in an area of environmental concern pursuant to 15'N'�AG—SVb0h,8iMr7K=.MO3.
Applicant Name
Address
City . 71,- CA
Project Location (County, State Road, Water Body, etc.)
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Phone Number '� 1,�-\ • , -A,:1 It
State iVC Zip
Type and Dimensions of Project `"��i�r�Y�. � ��.c,��. - E-�.n\UCH �: `i' La
The proposed project to be located and constructed as described
above is hereby certified as exempt from the CAMA permit re-
quirement pursuant to M NCAC-7K-'.0203. This exemption to
CAMA permit requirements does not alleviate the necessity of
your obtaining any other State, Federal, or Local authorization.
This certification of exemption from requiring a CAMA permit is
valid for 90ttays from the date of issuance. Following expiration,
a re-examination of the project and project site may be necessary
to continue this certification.
SKETCH �j (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.
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Applicant's signature
CAMA Official's signature
Issuing date
Expiration date
AttachMant:15 North Carolina Atfmtr~iisT-r-at ve Code-7K .0203