General Permits (423)

CERTIFICATION O F EX E M PT I`,
F
FROM REQUIRING A CAMA PERMIT APR 19Q?
as author!"d by the State of North Carolina,
Department of Environment, Health, and Natural Rosourcas and the CQ641tal Re
in an area of environmental ooncern pursuant to 16 NCAC Subchapter 7K .0203.---------------
Appliodrit
Address_
C'ity
Prolegt Lc
Type and Di
Ths proposed rvJpct to be located and constructed as described
above is hereby oert)fled a►s exempt from the CAW permit re•
quir4ment put cant to 15 NCAC 7K .0203, Th)s exem '
LAMA permit irequirements doe neceasity of
your obtainin ' a a, odors!, or Local authorization,
SKETCH
Any person who proceeds wfth it ctevalopment without the con-
sent of a CAMA official under tho mistaken assumption that the
development Is Oxompled, will be In violation Of the LAMA if thore
Is a subsequent determination that a permit was required for the
devolopinent,
I
The a$6-'ant cgrtffles by signing this exemption that (1) the ap-
plioaM has read and will abide by.the conditions of this exemp-
tion, Akhd (2) R wr Hen statement has been obtained from adjacent
landowners oor Ifying that they have no objections to the
proposed work. ,
Phone Numbe r ►-2q
atafe c Zip
This certification �,ojm requiring a CAMA permit is
valid s rem the dsuance, Following expiration,
re-examination of the project and project site may be necessary
tb Gontinue this certification,
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uAMA C.Mtctars signmum
Issuing ate
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xp rat►on dato --
_ I
Attachment: 1S North CarolinaAdministrative Code 7K.0203
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