General Permits (6874)

:,.... _ CERTIFICA?ION OF EXEMPTION R\cafe
FROM REQUIRING A CAMA PERMIT'
as authorized by the State of North Carolina,
Department of Environment, Health, and Natural Resources and the mmission
in an area of environmental concern pursuant to 3.
Applicant
City
Project l..ocatior
Type and Dimensions of Project
, Water Body, etc.)
rC—�LW Z(,
The proposed project to be located and constructed as described
above is hereby certified as exempt from the CAMA permit re-
quirement pursuant to This exemption to
CAMA permit requirements does not alleviate the necessity of
your obtaining any other State, Federal, or Local authorization.
Phone Numberltid - 94l V�_L4
L Zip
This certifica ion of exemption from requiring a CAMA permit is
valid r 90 day from the date of issuance. Following expiration,
a re -ex na ion of the project and project site may be necessary
to continue this certification.
I SKETCH (SCALE: t�1pNN�_Z )
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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.
(AMA Official's signature Q
issuing date
Expiration date
Alta e o e .02M