General Permits (6697)

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
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.
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.
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.
L_,
Applicant's signature
CAMA Official's signature
rAll�
Issuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

d SENDER:
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■ Complete items 1 and/or 2 for additional services,
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a Complete items 3, 4a, and 4b.
• Print your name and address on the reverse of this form so that we can return this
card to you.
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• Attach this form to the front of the mailpiece, or
ck if space does not
ipermit.
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■ Write "Return Receipt Requested"on th irp
o�t rticle number.
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• The Return Receipt will show to who e w
de' , nd the date
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delivered.
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I also wish to receive the
following services (for an
extra fee):
1. ❑ Addressee's Address
2. ❑ Restricted Delivery
Consult postmaster for fee.
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3, Article Addressed to: Cr n y
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4a. Article Number
3 11 393
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41b. Service Type
❑ Registered
Certified
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❑ Express Mail
❑ Return Receipt for Merchandise
❑ Insured
❑ COD
7. Date of Delivery
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5. Received By: (Print Name)
8. Addressee's Address (Only if
requested
and fee is paid)
oWC 6 Sign u e: dr r Ag
PS -Form 3811, December 1994 102595-98-B-0229
Domestic Return Receipt

UNITED STATES POSTAL SERVICE
• Print your
First -Class Mail
Postage^&;
USPS _..,
Pm Permit Na.�
e, address, and ZIP Code in this box •.i
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ADJACENT RIPARIAN PROPERTY Oti�N-ER STATENiEN-T
I hereby certify that I own property adiacent to (�tc:'USE �- I-L3C{�7 's
(Name of Propertv Owner)
property locar� at 20 �
(Lot, Block, Road, etc.)
CS f_,STA-T'
1 on , in F _c Ret_ -- ,'cam N.C.
(% "aterbody) (Town and/4 County)
He has described to me as shown bellow, the development he is proposing at that Iocadon,
and; I have no objections to his proposal.
DESCRIPTION AND/OR DRANNT�G OF PROPOSED DEVELOPNUNT
(To be filled in by individual proposing development)
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Print or Type Nam. -
Telephone
Date:

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