01023D - McCuistion

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�plicant Name
(dress
:y
0ject Lo , tior
CERTIFICATE OF EXEMPTION
FROM REQUIRING A LAMA PERMIT l( �� 01
as authorized by the State of North Carolina,
Department of Environment and Natural Resources and the Coastal Resources CoLnIpission�
in an area of environmental concern pursuant to 15 NCAC S cha ter 7K t J
QiV iy 1 �( ��>�(/ Phone Number
M
nty, State Road, Water Body, etc.)
proposed project to be located and constructed as described
ve is hereby certified as exempt from the CAMA permit
iirement pursuant to 15 NCAC 7K rl t 7. This exemption
:AMA permit requirements does not alleviate the necessity of
r obtaining other State, Federal or Local authorization.
State
zip
This certification of exemption from requiring a CAMA
valid for 90 days from the date of issuance. Following ex
a re-examination of the project and project site may be r
to continue this certification.
KETCH (SCALE:VV
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AL

HCDEHR
North Carolina Departrnent of Environment and Natural Resources
Division of CoasW Management
Pat McCrory Brmlm C. Dens John E.
Governor Director so
AGENT AUTHORIZATION FORM
Date: / 0- Z
Name of Property Owner Applying for Permit Name of AuIhoriosd AOsirt fpr this project.&"Ok 1qeL)s'4i4
owners 11 rgAddress:
rarer 2 Sse,,A_r 4 fir.
Phone Number (9'i/��: n s' 5 C2
I oar* that I have such dmd the agent Msled aWn to ad on my behalf, for the purpose of applying
for -mid obtaining al LAMA Pwff*s necessary to instaN or coneftid the WowkV (sc&*):
S -
K�7i2!X 7=Z2i2t f �✓G
For my property Wcood at
This oe Wvcgdm is v#Md thru (dole)
Property OWNW Oyrro"ro Dols