01520D - Golub

'Pil 3. 14
CERTIFICATE OF EXEMPTION
FROM REQUIRING A LAMA PERMIT ' � 01.1
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 ,
flicant Name �OWV't (- ol vk CJ v Au+�C1 6rV �-6-(:PhoneNumberj
tress -kIM5< AVeylv<
f M o ,'A- State Zip 0�
ject Location (County, State Road, Water Body, etc.) ►C c
nq Ci,J �21,--^ -rco I ?A (Art. ! 1-P T--rAvks Pin L � kip nk
e and Dimensions of Project
proposed project to be located and constructed as described
e is hereby certified as exempt from the CAMA permit
rement pursuant to 15 NCAC 7K rl " . This exemption
kMA permit requirements does not alleviate the necessity of
obtaining other State, Federal or Local authorization.
This certification of exemption from requiring a CAMA p
valid for 90 days from the date of issuance. Following ex�
a re -examen n of the project and project site may be nE
to continue this certification.
;ETCH (SCALE:
4
------------
i
Cox ►G� ;
�p�JtJ 6�
i

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: � b(r + U 70/Uf
Mailing Address:
Phone Number:
Email Address:
I certify that I have authorized
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&—ei ' /j/p
bitl/C '4y( - 01
at my property located at
in _ /J/.1PSt,)I' L County.
l furthermore certify that l 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:
Signature
P—c-D-6C'-�fl1A�L—
Print or Type Name
Title

J-

�.� �• � dM•ye- yi, t
ns. -