Crabtree

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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.
cant Name Phone Number 1 SAS -
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Z2 State Zip 2
ct Location (County, State Road, Water Body, etc.)
and Dimensions of Project q V
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roposed project to be located and constructed as described
is hereby certified as exempt from the CAMA permit re-
nent pursuant to 15 NCAC 7K .0203. This exemption to
\ permit requirements does not alleviate the necessity of
)btaining any other State, Federal, or Local authorization.
This certification of exemption from requiring a CAMA pen
valid for 90 days from the date of issuance. Following expir<
a re-examination of the project and project site may be nece�
to continue this certification.
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AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit:
Mailing Address: %J / 7 h A�n5e—
Cal AA- a 92-2-7
Phone Number: ��,� - > �S 9&17
Email Address: (— t i s y 0&/ 3 35 a! V%1�wz> , 6U-7,�
I certify that I have authorized e�6/11 !e tn&S /' `' f t -4"n CO C:�5 l c�o
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: 1-wail`
Gh6ve Gi�SS
at my property located at
in 16/'at+sIrcK
County.
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I furthermore certify that I am authorized to grant, and do in fact grant permission to
Division of Coastal Management staff, the Local Permit Officer and their agents to enter
on the aforementioned lands in connection with evaluating information related to this
permit application.
Property Owner Information:
—r—
Signature
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Print or Type Name