General Permits (7041)

CERTIFICATION OF EXEMPTION � �`�
FROM REQUIRING A LAMA PERMITauthorrr.ed by the State of North Carolina,
Dtpartrnent of Environment, Heaith, and Natural Resources and the Coastal resources Con-imis
in an area of environmental concern jp�Lfisu�ant to 15 NCAC Subchaptar 7K .0203.
Applicant Name -
Address — - Pra e
Project Locati fin• (County, St a Road, WJayy Body, efc)
Type and Dirnenslons of Project
T^a pruoosed project to be locatsd and coistructed as describad
above is hereby certified as exempt from the LAMA permit re-
quiramsnt pursuant to 1: NCAC 7K .M03. Tnix exemption to
LAMA permit requirements does not alleviate the necassity of
your obtaining any other State, Federal, or Local authorization,
Phone Number _• _ _
zP
This certification of exemption from requiring a LAMA permit is
valid fork days from the date o! ;ssuanco. Foilowincg expiration,
a re-examination of the project and pro�ov. %'to may be iecas ,ary
to continue this certification.
i SI<ETCH rfi4-L (SCALE: &fs
Any person vtho proceeds with a development withcut the Con-
sent of a CAMA official under the mistaken assumption that the
development Is axampted, will be in violation of ttta GAMA if there
is a subsequant determination that a perm t was required fnr the
development.
The applicant cartifies by signing this exemption that (1 ) the aD-
plicamt has road and will abide by the conditions of this exemp-
tion. and (2) a writt®n statement has been obtained from adjacent
landownars certifying that they have no objections to the
propo"d work-
nt's atonature
CAVA Official's signature
Issuing date
DIM -
Expiration
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At a&mom: 15 Norm Ca-olina Adm)nisirauve Code 7K ,0203