General Permits (416)

CERTIFICATION OF EXEMPTION
FROM REQUIRING A CAMA PERMIT /j/�,, 6 x
as authorized by the State of North Carolina,
Department of Environment, Health, and Natural Resources
in an area of environmental concern pursuant to 15 NCACj
Applicant Name J A I i;
Address
City
Project Location (County, State Road, Water Body, etc.)
r
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.
ta
eCoastal�Uources Commission
pter 7K .0203.
Phone Number
State 14% 4,1111 Zip S 9
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: ) I
,� `f /
,Fars �
r �
1
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.
Applicant' sign a u;e
C MA Official's signatudd
Issuing date
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

ACENT RIPARIAN PROPERTY Oi,NNER STATEMENT
I hereby certify that I own property adjacent to
r '/I ✓ is property located at
(N Of —Property Owner)
(Lot, Block, Road, etc.)
on O[ L(1� l/ 1���. , 3.n
�Ly%s �,. N.C.
(Waterbody) (Town and/or County)
He has described to me, as shown below, the development he is
proposing at that location, and, I have no objections to his
proposal.
-------------------------------------------
--------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT;
(To -- d7�71' a,�pq�iYjdual proposing de"ip eat- _
t i- I
LI
Signature
Print or Type Name
G�37� 23�d
Telephone Number
,? a I�e % H-
I
r

-' . r
ADJACENT RIPARIAN- PROPERTY U"WER STATEKENT
iv)
I hereby certify that I own property adjacent to
's property located at
Name of Property Owner
Lot, Block, Road, etc.
on /�1�i✓mac � �'.0 � ..� , in
(Waterbody) (Town and/or County)
He has described to me, as shown below, the development he is
proposing at that location, and, I have no objections to his
proposal.
-- -r----------------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be1C�t1� proposing develop�n)—.---
. - .A,
1 �ure
Print or Type Name
Telephone Number
i✓J