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plicant Name
dress i
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CERTIFICATE OF EXEMPTION
FROM REQUIRING A LAMA PERMIT ;;;'Ya 01
as authorized by the State of North Carolina, ATTFqL w
Department of Environment and Natural Resources and the Coastal Resources Commission
in an area of environmental concern pursuant to 15 NCAC Subchapter 7K .
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ject Location (County, State Road, Water Body, etc
--e_ ti
e and Dimensions of Project
proposed project to be located and constructed as described
ve is hereby certified as exempt from the CAMA permit
uirement pursuant to 15 NCAC 7K . This exemption
:AMA permit requirements does not alleviate the necessity of
it obtaining other State, Federal or Local authorization.
Phone Number
State J
Zip
This certification of exemption from requiring a CAMA
valid for 90 days from the date of issuance. Following e;
a re-examination of the project and project site may be i
to continue this certification.
;KETCH (SCALE:
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AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit
Mailing Address: AD �/"SXf/
Phone Number: 37,30— 6 9 0 7
Email Address:
certify that I have authorized. -�i'�f her` to / Gt 1�,1
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all LAMA permits
necessary for the following proposed development: Pe, � I r j b dame lac!
p � �� iAJ
at my property located at
in auk 4!V (:k County.
1 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:
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