The

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.
licant Name rw ?6'(.LC 06� IXir + (";(I Phone Number gto1*S l (�23
ress_ 1DSO Sk&(10 +C ?' L.cW
4�"tto4i-t State A'. Zip 1
ect Location (County, State Road, Water Body, etc.) ,i iv
071J1.J iJ. IRS V.Ilaet -Pn,-^ - ;. ,ar- N"(1.44-c
and Dimensions of Project
proposed project to be located and constructed as described
re is hereby certified as exempt from the CAMA permit re-
)ment pursuant to 15 NCAC 7K .0203. This exemption to
1A permit requirements does not alleviate the necessity of
obtaining any 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-examination of the project and project site may be necE
to continue this certification.
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Post Hurricane Matthew Damage
Inlet View Grill — 1800 Village Point Rd., Shallotte (11/01/2016)

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: IIMII�, /1e4
Mailing Address: % U U
Phone Number:
Email Address:
I certify that I have authorized
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�e-9v;A-*I � gL c. t'?-e /L
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
at my property located at / � 0 v
in c 4- County.
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:
Signature
Print or Type Name