General Permits (6516)

CERTIFICATION OF EXEMPTION /��a �
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
Address
Citv
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.
Phone Number
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.
SKETCH (SCALE: ) ,
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/Any persUn WnU p1UG(-'eU5 WIL11 d UCVCIV'.JIIIGIIL WIL11VUk LllG WI[ -
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.
i
Applicant's signature
CAMA Official's signature
ing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

Permittee's Name erml n _
Location: S ( _ Fi d Rep. t (�
Phone: Date of Report: C�
Description of Project:
Date Project Reportedly Compfftte:
(1) Do the measured dimensions of the developm iffer from those
indicated in the permit .an plat? Yes / No Have all permit
conditions been satisfied? s No
COMMENT:
(2) Sedimentation and Erosion Control: Has permitt-e seeded, grassed,
or other -raise stabilized all disturbed area / No
COM2,11-ENT :
(3) Future Monitoring and forcemeat Action- Is'further investigation
or enforcement action needed? Ye / N
COMMENT:

0'(� ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to �/E�F,�r Jr Sc�148E.p6 's
(Name of Property Owner)
property located at 524 10i&
(Lot, Block, Road, etc.)
Oil in eg& efgrrk,(r , N.C.
(Waterbody) (Town and/or County)
He has described to me as shown below, the development he is proposing at that location,
and, I have no objections to his proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(To be filled in by individual proposing development) � ,D
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I(P
Signature
aN,A&'2 1/ C-O C U /Aj
`'Print or Type Name
!ZZ � 5 ��_� �T z- cs
TeTlephone Number
Date: Zz> - 17

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to -,-!ed#A('ez I
(Name of Property Owner)
property located at '� Nf1-%6C )Z
(Lot, Block, Road, etc.)
on ��� �/ in l'P�t�.eET N.C.
(Waterbody) (Town and/or County)
He has described to me as shown below, the development he is proposing at that location,
and; I have no objections to his proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(To be filled in by individual proposing development)
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Signatur
Iq a rcj
Print or ype Name
Telephone Number
Date: 16 - � - ?I