Joseph Blake

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 15 NCAC Subchapter 7K.0203.
Applicant Name po s r f'w► lac-..14-c Phone Number (J4 0) 32'1-3c 33
Address 104 5 ,o.cc
City WIifcr-1 ;v, State Zip 2Z Go1
Project Location (County,State Road, Water Body,etc.) es,,,,,,,,,,,w-
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Type and Dimensions of Project
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The proposed project to be located and constructed as described This certification of exemption from requiring a CAMA permit is
above is hereby certified as exempt from the CAMA permit re- valid for 90 days from the date of issuance. Following expiration,
quirement pursuant to 15 NCAC 7K .0203. This exemption to a re-examination of the project and project site may be necessary
CAMA permit requirements does not alleviate the necessity of to continue this certification.
your obtaining any other State, Federal,or Local authorization.
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Any person who proceeds with a development
without the con- � .}t.-e• `' . ‘ e/--4-c...---- ----
sent of a CAMA official under the mistaken assumption that the Applicant's signature
development is exempted,will be in violation of the CAMA if there �,r.a—J j. 1c •
is a subsequent determination that a permit was required for the CAMA Official's signature c�/r¢`"
development.
The applicant certifies by signing this exemption that (1)the ap- Issuing date
plicant has read and will abide by the conditions of this exemp-
tion,and(2)a written statement has been obtained from adjacent S /i ci
landowners certifying that they have no objections to the Expiration date
proposed work.
Attachment: 15 North Carolina Administrative Code 7K.0203

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North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Pat McCrory Braxton C. Davis John E. Skvarla, III
Governor Director Secretary
AGENT AUTHORIZATION FORM AGENT i . r — ON FORM
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Pat McCrory Braxton C. Davis John E. Skvarfa, Hi
Governor Director Secretary
Date: i1 ( IZO( 9
Name of Property Owner Applying for Permit: Name of Authorized Agent for this project:
Owner's Mailing Address: Agent's Mailing Address:
(r ( '6CA-c14t Q e2Scfb 9
Phone Number (5 )) 3627 --5o33 Phone Number
I certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
for and obtaining all CAMA Permits necessary to__C)-install or construct the following (activity):
�r\5 1� yiJ l (-1-C-V � Wes\I
4 127 Cardinal Drive Ext..Wilmington.NC 28405
Phone:[phone] t FAX:[phone] Internet:www.nccoastalmanagement.net
An Equal Opportunity',Affirmative Action Employer

For my property located at p ZAJ, 6 De_i tic OCik") /4cr 6E 1 'C %
This certification is valid thru (date) Al, 90( 1
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;�•erty Owner Signature Date

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