Worthington

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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.
C/
cant Name e r r 0 �� � `��Phone Number Zl
ess
<'e State Zip
act Location (County, State Road, Wate Body, etc.)
and Dimensions of Project
roposed project to be located and constructed as described
is hereby certified as exempt from the CAMA permit re-
pent pursuant to 15 NCAC 7K .0203. This exemption to
% permit requirements does not alleviate the necessity of
)btaining any other State, Federal, or Local authorization.
This certification of exemption from requiring a CAMA pert
valid for 90 days from the date of issuance. Following expiry
a re-examination of the project and project site may be nece!
to continue this certification.
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AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Applying for Permit: �" ►1 T7 L`� G� LAJ t? l v V 11 r Tt
Mailing address: ti b � t v ey Dr
Phone Number: _ y ILf S
I certify that 1 have authorized [�) -3 im 1, T-h
nt- Contractor
to act on my behalf, for the purpose of applying and obtaining all CAMA permits
necessary for the proposed development of B _ .oai r S a Y-e y-2c t C�
at my property located at rl 0 C �W
in County.
This certification is valid through
(Property Owner In 7��n)
f.. t
Signature L
Q ,} c 4- YINPrint or Type Name
tv tier
Title
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Date
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Phone Number �
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