General Permits (8219)

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Applicant
Address _
City
Project Lc
CERTIFICATION OF EXEMPTION
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 AACf /1�
C'ft� �� �d� %• r"Pid� Phone Number
State Road, Water Body, etc.)
State
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 .NCAG 71K:02ea.' This exemption to
CAMA permit requirements does not alleviate the necessity of
your obtaining any other State, Federal, or Local authorization.
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 SKETCH (SCALE: )
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)-awritten statement-has'been,ebtained from adjacont
landowners. certifying -that-,they have-, no-objectiont" 'to the
proposed work.
Applicant's signature
CAMA Official's signature
Issuing date
Expiration date
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