General Permits (6719)

-�r- CERTIFICATION OF EXEMPTION��
s
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
hin an area of environmental concern pursuant to 15 NCAC Subchapter 7K .0203.
Applicant Name
Address
City
Project Location (County, State Road, Water Body, etc.)
Phone Number -? , i
State Zip
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.
This cr. rtification of exemption from requiring a LAMA -permit is
valid-for-90-days from the date of -issuance. Following -expiration,
a re-examination of the -project and project sitemay be necessary
to continue this certification.
Applicant's signature
CAMA Official's signature
Issuing date
Expiration M6
Attachment: 15 North Carolina Administrative Code 7K .0203

ADJACENT RIPARIAN PROPERTY O R ST eTEMM
hereby certifythat I own property adjacent to
P Y J
(Name of Property Owner)
property located at
(L,6t, Block, Road, etc.)
on ��t' Gc� �-'2 , in ,.t e") .C;" , 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.
DESCREMON AND/OR DRAWING OF PROPOSED DEVELOPMENT
i. (To be filled in by individual proposing development)
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(�, Ne a S2 R, veM-
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Print or Type Name
Telephone Number
Date: - - G) o

" ^ ADJACENT RIPARIAN PROPERTY O R ST4TEME
I hereby certifythat I own property adjacent to
P P Y J
1 (Name of Property Owner)
property located at
// y
t, Block, Road, etc.)
on ��.� ,f G� clGt , in "/t z �, N.C.
(Waterbody) (Town and/or County)
He has described to me as shown below, the development he is proposing at that locadQn,
and, I have no objections to his proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
a (To be filled in by individual proposing development)
Ne u Se, Ri ve &
� ko ak
VIA
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h
Pape ose r ?o 9149M p „ 0046e R o-�
pIA(Q�od [/ /N IJ�gB�
ignature
Print or Type Name
(&f 2) &36 - �6 Z f"
Telephone Number
Date: - - o 0