General Permits (6761)

CERTIFICATION OF EXEMPTION y
FROM REQUIRING A CAMA PERMIT V
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 fJ;
Address
City State Zip i
Project Location (County, State Road, Water Body, etc.) << t
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.
This cc-tification 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
tJv1� '
- - -- ''tOC> FT.
Any person who proceeds with a development without the con-
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.
1r4," t1Jo1 E'Pr'-.
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Applicant's signature
CAMA Official's signature
Issuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

ADJACENT RIPARIAN PROPERTY OWNER STAI.-F2VIEM'
I hereby cerdiy that I own property adjacent to ,/�4 =
(Name of ]P'ropei-ty Own
property located atjlZtot,�Blau, Ptoad,
on — �N.C.
In Jl1 _ _
(j^iaftibodyj ('town and/or Copr y) - _..�
He has dpsr:?..;hed to me as shown below, the development h^ is uroposing at that location,
and, I h;wF no ,)Er+fctionS to his proposal.
4r/S 1`J''
f31OPeA0
°7 ON AND/OR DRAWING OF PROFi`4'VTj,j)pT'��
(To be filled in by individual proposzn�
Ulf
Ic nature
' Print or Type Name
Telephone Number
Date: _ j / r q I

ADJACENT RIPAPUIN PROPERTY OWNER STA7:t�:AT ;"�, '
I hereby certify that I own property adjacent to LT 2 S
ame of Propez .; �0,mer3
property located at__, ��.Z /- �7
(Lot, Block, Road, etc.) �!
a
on m�z�r _ I� . C.
M� aterbody) (Town and/or County)
He has described to me as shown below, the development he is prop-,
and, I have no oF,jfc.; as t� his opo
DESCRTP'd ,:4 AND/OR DRAWING OF PROPOSED
(� .0ed in by individual proposing developr,-eni)
`17 ,c�-- qC S c- � / t- E I',
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B4-,�r-ltC4ia
�gnure — - -- I
Print or Type Name
-� �-L — Pj _
Telephone Numue,
Date: