Vandergrift

P try 4.7.1 ~7
)plicant Name
'dress
ty
pe
CERTIFICATION OF EXEMPTION
FROM REQUIRING A CAMA PERMIT
as authorized by the State of North Carolina,
Department of Environmental Quality and the Coastal Resources Commission in an area of
environmental concern pursuant to 15 NCAC Subchapter 7K ?L-ior NCGS 113A-103 (5) (b) (5)
of Proj
State Road, Water Body,
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
lorization.
Phone Number (410)70
State N L Zip
This certification of exemption from requiring a CAMA F
is valid for 120 days from the date of issuance. Followinc
expiration, a re-examination of the project and project sit(
be necessary to continue this certification.
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-;
AA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Pat McCrory Braxton C. Davis
Governor Director
AGENT AUTHORIZATION FORM AGENT i ON FORM
_ —
AI
ga�
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Pat McCrory Braxton C. Davis
Governor Director
Date: tjAgg it 20/ rJ
Name of Property 70ZnerApplying for Permit:
AC l7
John E. Skvarla, III
Secretary
John E. Skvarla, III
Secretary
Name of Authorized Agent for this project:
v �, � CQ (_ nSs uC � 0 n
Owner's ail' g Address: Agent's Mailing Address:
i 10�7asNr�P.C- pie. 1Z, AV 6
tit ds i Erwal 46, 22
Phone Number ( o) 2�>3 jEgG2 Phone Number ("I N) S-I4 -q6 C6
I certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
Pnr �nrl �11 i`A11AA D—i+e, +_ ;__+_Il ...........+.. ...++L... /.. s:.AS-1k.

For my property located at
Sf�OIZE ,DID Su/Y.Sc:`—T �t�Gl�. �G ZJ
This c ific ion is valid thru (date)Ij
3
erty Owner Signature Date

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