01561D - Chao

CERTIFICATE OF EXEMPTION
FROM REQUIRING A LAMA PERMIT
as authorized by the State of North Carolina,
Department of Environment and Natural Resources and the Coastal Resources Commission
in an area of environmental concern pursuant to 15 NCAC Subchapter 7K
Iicant Name N < �Sr/Y) V or Nn 61 I\ a
ress 4( -+, \, ; \ d V
ect Location (County, State Road, Water Body, etc.)
e and Dimensions of Project
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)roposed project to be located and constructed as described
is hereby certified as exempt from t4e CAMA permit
-ement pursuant to 15 NCAC 7K T j f . . This exemption
AMA permit requirements does not alleviate the necessity of
obtaining other State, Federal or Local authorization.
'V\ S
Phone Number -
tCA
Zip
This certification of exemption from requiring a CAMA pE
valid for 90 days from the date of issuance. Following expi
a re-examination of the project and project site may be ne
to continue this certification.
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NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
it McCrory Braxton C. Davis John E. Skvarla
'ovemor Director Secretary
AGENT AUTHORIZATION FORM AGENT AUTHORIZATION FUKM
Date: 4-bi / 16
ne of Property Owner Applying for Permit:
e 15 o n i E
ner's Mailing Address:
rc r% d 222, N G', 2 7 71
me Number01" P 2-q--3 6 12-
((Name of Authorized Agent for this project:
Agent's Mailing Address:
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Phone NumberdAW s %q-- q0
rtify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
and obtaining all CAMA Permits necessary to install or construct the following (activity):
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A r +' 01,v eq
my property located at 4 2 7 ,-),7io r 1i a/
certification is valid thru (date)
Property Owner Signature Date
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