General Permits (7258)

CERTIFICATION OF EXEMPTIO
Applicant Name 2 i • i Phone Number
Address
City f / v- h r'=+ e'
Project Location (County, State Road, Water Body, etc.)
sof.
ffn� 1;«�..r� , ��► ,� v-
na..�..-s
o be located and constructed as described
15 NCAC 7K .0203. This exemption to
�f f
ed, will be in violation of the CAMA if there
urination that a permit was required for the
by signing this exemption that (1) the ap-
ill abide by the conditions of this exemp-
ments does not alleviate the necessity of
under the mistaken assumption that the
that they have no objections to the
Project
e
State /1 Zip
Typ� and Dimensionon22
The proposed project t
above is hereby certified as exempt from the CAMA permit re-
quirement pursuant to
CAMA permit require
your obtaining any other State, Federal, or Local authorization.
i
ry
This certification 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 necessa
to continue this certification.
SKETCH
mom M ENO 0 %_l mom
NONE
NO NOOSE
NONE
ME - = - -
Any person who proceeds with a development without the con-
sent of a CAMA official
development is exempt
is a subsequent deter
development.
statement has
The applicant certifies
plicant has read and w
lion, and (2) a written
been obtained from adjacent
landowners certifying
proposed work.
Applicant's signature
CAMA Official's signature
Issuing dated —%—
Expiration "date
Attachment: 15 North Carolina Administrative Cade 7K .0203