General Permits (8201)

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4 CERTIFICATION OF EXEMPTION
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FROM REQUIRING A CAMA 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 State
Project Location (County, State Road, Water Body, etc.)
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.
Phone Number
Zip
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 necessary
to continue this certification.
I l' l
I SKETCH (SCALE: i % )
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.
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Applicant's signature
1
CAMA Official's signature
1
Issuing date
/ir
Expiration date ! i
Attachment: 15 North Carolina Administrative Code 7K .0203

I hereby certify that I own property adjacent to
M-31FILT Z L4 3 R l -S is property looted a t
(Nacre of Property Owner)
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(Lot, $lock, Road, etc.)
ca i3O G U� Sa ��1� in t.h�R7L O L1SL c . C.
(Waterbody) (To;&m and/or County)
The applicant has describe: to tr::, as Shown below, the d=_velopme-:t
proposed at the above location. I understand that any constr-,ction,
excluding bulkheads, must be set back a minimum distance of fifteen fees
(15') from my area of riparian access unless waived by me.
-XI have no objection to the proje=- as propose^ b,-t do not wish tz�
waive the (15') setback requir meat.
I have no objection to the project as proposed and do w; sh to wive
the (15') setback recuirem:ent.
I object to the project as proposed.
=S='PTION k' WOR
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al proposing develo?::ent)
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Print or _ Name Sicmna
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�ephone Nrrber Ik et

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ADJACENT' RIPARIAN PROPERTY OWNER STATEmE Tr
I hereby certify that I own property adjacent to
's property located at
(Name of Property Owner)
(Tot, $lock, Road, etc.)
on _i3 a G U C Go LlIK 7 in tz: MIEiL�IL p
(Waterbody) (Town and/or County)
The applicant has described to me, as shown below, the developrmnt
proposed at the above location. I understand that any construction,
excluding bulkheads, must be set back a minimum distance of fifteen feet
(15') frcm my area of riparian access unless waived by me.
—
I have no objection to the project as proposed but do not wish to
waive the (15') setback requirement.
I have no objection to the project as proposed and do wish to waive
the (15') setback requirement.
I object to the project as rrc:�osed.
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DESCRIPTION 7-LNID/OR DR OF PROPOSED DEVEIIOP,ENT: J/44)
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Print or Type Name
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Ttlephorfe Number
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