General Permits (6543)

CERTIFICATION OF EXEMPTION
Applicant Name
Address �36) ,
City A
Project Location
FROM REQUIRING A CAMA PERMIT fir Al
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 NCAG Subchapter-7K-:0283. 1,0 _ gOO-3
CSCp 7e t Phone Number -
Type and Dimensions of Project K e 4 f4 1 2"J X e ' ; ,4A 4- Q 1
4.. !. J. - e,Ml ..• / . Z' . /i C>
The proposed project to be located and constructed as described
above is hereby certified as exefnpl from the CAMA permit re-
quirement pursuant to 1;5A6AC-*--G203: 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 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 person wno proceeas w+m a aeveiopmem wnnuw uie uuw
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.
Applicant's signature
LAMA Off 1cial's`signature
4' d1t, k�,
Issuing date
Expiration date
Attachment: