01545D - Havlin

CERTIFICATE OF EXEMPTION _
FROM REQUIRING A LAMA PERMIT 01k
as authorized by the State of North Carolina,
Department of Environment and Natural Resources and the Coastal Resources Com fission
in an area of environmental concern pursuant to 15 NCAC Subchapter 7K. � M ow)
icant Name Phone Number
State Ziala
:ct Loca on (County, State Road, Water Body, etc.) L a 4-r C1
ti -
,1 1-1 11
and Dimensions of Project
Y-PA (A(( e rn t L-c-4,vN
roposed project to be located and constructed as described
is hereby certified as exempt from the CAMA permit
ement pursuant to 15 NCAC 7K t 1 t 7 . This exemption
MA permit requirements does not alleviate the necessity of
)btaining other State, Federal or Local authorization.
This certification of exemption from requiring a CAMA pe
valid for 90 days from the date of issuance. Following expi
a re -examen' at on of the project and project site may be nec
to continue this certification.
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as authorized by the State of North Carolina,
Deparunent of Environment and Natural Resources and the Coastal Resources om Isslon
in an area of environmental concern pursuant to 15 NCAC Subchapter 7K- , - I ) 411-6174-1 Ag
Applicant N me .�p
(i- ►1(, Phone Numbe , ' 3
Addrevls , ✓i YG
State r zp vitae
in (County, State Road, Water Bod , etc.) J .L
A A ' . - tM ,t•, -
Type and Dimensions of Project —Q i �� �e GC.C.Ety�
The proposed project to be located and constructed as described This certification of exemption from requiring a CAMA pemtit I
above is hereby certified as exempt from the CAMA perntlt valid for 90 days from the date of Issuance. Following expiration
requirement pursuant to 15 NCAC 7K v� This exemption a re-examfitatfon of the project and project site may be neeessar
to CAMA pennit requirements does not alleviate the necessity of to continue this certification.
your obtaining other State, Federal or Local authorization.
SKETCH
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AGENT AUTHORIZATION FOR LAMA PERMIT APPLICATION
Name of Property Owner Applying for Permit:_ h j
qV
Mailing address:
Phone Number:
certify that I have authorized V �' L arc--
Agent / Contractor
to act on my behalf, for the purpose. of applying and obtaining all CAMA permits -
necessary for the proposed development of z�(&kr-„� C
at my property located at 17 �cL✓� �rri ��-
in /�ruPl?Y✓tcCounty.
This certification is valid through _ _ /� Li1 �1(,
Date
(Property Ownor Information)
Signature
Print or Type Name
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Title
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