Miller (3)

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CERTIFICATION OF EXEMPTION
FROM REQUIRING A CAMA PERMIT
as authorized by the State of North Carolina,
Department of Environmental Quality and the Coastal Resources C mmission in an area of
environmental concern pursuant to 15 NCAC Subchapter 7K , a(p,k NCGS 113A-103 (5) (b) (5)
)plicantName uyaa ". &rust Phone Number
(dress C] 2- 1 ( o"'rJ
ty ( 1A vrl ° ti-e- State
L Zip � �
proposed project to be located and constructed as
;ribed above is hereby certified as exempt from the
AA permit requirements. This exemption to CAMA
nit requirements does not alleviate the necessity of
obtaining any other State, Federal, or Local
iorization.
This certification of exemption from requiring a CAMA r
is valid for 120 days from the date of issuance. Followinc
expiration, a re-examination of the project and project sits
be necessary to continue this certification.
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A"J
NCDEWR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue Braxton C, Davis Dee Freeman
Governor Director Secretary
AGENT AUTHORIZATION FORM
Date: W!!!i i i z U 1-'-1
Jame of Property Owner Applying for Permit: Name of Authorized Agent for this project:
ea) w*,A- a Qkz V"k1".,2 _ NS ocv,s'Fakc-t7u-\
Mner's Mailing Address:
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C1 ,Z�o z N C Zg2,Zs-
hone Number S q°'fi :g I cl - ° (6 19
Agent's Mailing Address:
z�912 der vl,--'6 b1ac'JZ , S W
S S T NC -zg4 2
Phone Number f 0 gb— 4 2
certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
it and obtaining all CAMA Permits necessary to install or construct the following (activity):
Dr my property located at q °+ ()C.4 ".-" UJA r Oc e,^' gam` /Ne 2
lis certification is valid thru (date) _ ucu...i 3 u, 20 ► —7
sl/Izci-?
Property Owner Signature Date