General Permits (6124)

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
in an area of environmental concern pursuant to 15 NCAC Subchapter 7K .0203.
Applicant Name �/" '� Phone Number
Address
City
Project Location (County, State 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.
State
Zip
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.
I SKETCH (SCALE: ) I
Any person who proceeds with a development without the con- ' tom', ;>'�r,_
sent of a CAMA official under the mistaken assumption that the Applicant's signature ,
development is exempted, will be in violation of the CAMA if there {.
is a subsequent determination that a permit was required for the
development. CAMA Official's signature
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.
Issuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

ti
ADJACENT IRIPARLkN--T"�)PFr&TY OWNER STATEME-ENT-,
I hereby certify ttiat I own prope-,,;
2,1,jacentto
(Name
Na e o
property located at
Binck, Road, etc.) J0
on
(W
x, r aterb o dy) -
'�'�(�To �anelo�rCo County) In
He has desci-;','-,-;d beloww -i
the development he s propot!.-!g
Ixi? Ion
and; I have no object.ur-,, p.
DESCPj?jj �k 7i—
-A
J, ]1\GOFPROPOSEDDE��-V
frjdjjjdual proposing development)
Signature
L:
Print or Type Name
L
Telephone Number
C
Date:

^ ADJACENMT. _PJTARLAN PROPERTY OWNIM STAIRDWT
X ea�by cax•E p;` ° at I own Property adjacent to
31
koy, Omer)
property
•, — -_. __ . (pot9 Block, Road, etc.)
on
in
u own atilt: Q`'
• =fir" 7ar;: l�" me -as -Shown below, the develops nent;: ;Y %f:at lo
cation
on
and, I h-ave :ii y= s to h1s _ -
pcop�.,z1.
/OR DRA ING OF PROPS
0 be,lPed if.: -by Iradivid�ral
--------------
1.
Sign• U
Rot, Itizie t J
Pri,1t oc Type Name
Telephone slumber
Date: _ / O-Z — —/ -- ��