General Permits (6791)

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CERTIFICATION OF EXEMPTION��-�-;L,j
FROM REQUIRING A LAMA 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
State
Phone Number
Zip
The proposed project to be located and constructed as described This certification of exemption from requiring a CAMA permit is
above is hereby certified as exempt from the CAMA permit re- valid for 90 days from the date of issuance. Following expiration,
quirement pursuant to 15 NCAC 7K .0203. This exemption to a re-examination of the project and project site may be necessary
CAMA permit requirements does not alleviate the necessity of to continue this certification.
` yyour obtaining any other State, Federal, or Local authorization.L
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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.
Applicant's signature
CAMA Official's signature
Issuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

ADJACENT RIPARIAN PROPERTY OW^MM STAi EMENT
I hereby certify that I own property adjacent to V tt- I !L,\ iu s
�( (Name of Property Owner)
property located at �C A
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J (Lot, Block, Road, etc.) on �,l (��, �l y- , in 5 L,0 ,? v\' 5 6"try
(Waterbody) (Town and/or County)
N.C.
He has described to me as shown below, the development he is propos'^ at that location.
and, I have no objections to his proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(To be filled in by individual proposiizb development) f
P.kSisfi/D'
. mature
Print c . Type Name
'-lephone Numb —
Date: 1 L�
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ADJACENT RIPARIAN PROPERTY OWN, STAi EMENT
I hereby certify that I own property adjacent to�� \��� �' is
(Name of roperty Owner)
property located at /
j 11 y1 (Lot, Block, Road, etc.)
on 4L_ (1Ck K L`k in u�� �� 1
(Waterbody) (Town and/or County)
N.C.
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)
y
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Print or Type Name
�.S"2- -Z_3 3�
'-,lephone Numb( ---
Date: