General Permits (6003)

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Applicant Name
Address
City
CERTIFICATION OF EXEMPTION
FROM REQUIRING A CAIEIIT
as authorized by the State of North C2rfa, -'------
Department of Environment, Health, and Natural Resources and the Coastal Resources Commission
in an area of environmental concern pursuant to 15-NCAC Subchapter 7K .0203.
Project Location (County, State Road, Wate[ Body, etc.) k:
Phone Number
_ State VvL p A IV-
-
Type and Dimensions of Project �-vr,.. �, ,,�•, 4. t _ .--
k7
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.
This certification of exemption from requiring a CAMA permit is
valid forgo 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 (SCALE: ) I
t.l E I ti -- ,
1 tL
Anv nnrenn whn nrnenadQ with it HavP.Innmont wlthnut the can-
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.
0
Applicant's signature
CAMA Official's signature
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Issuing date
Expiration date
Attachments-15-North Carolina-'A�inistrative Code 7K .0203