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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.
elicant Name i —6 fi t- (/J �'►� K 1-/ d X'J Phone Number
9ress
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)ject Location (County,
)e and uimensions of Frotect
proposed project to be located and constructed as described
ive is hereby certified as exempt from the CAMA permit re-
'ement pursuant to 15 NCAC 7K .0203. This exemption to
MA permit requirements does not alleviate the necessity of
r obtaining any other State, Federal, or Local authorization.
This certification of exemption from requiring a CAMA p,
valid for 90 days from the date of issuance. Following exp
a re-examination of the project and project site may be nec
to continue this certification.
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North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Pat McCrory Brwdon C. Dams John E. Sk
Govemor Dkector Seca
AGENT AUTHORIZATION FORM
Date:
Name of Property Owner Applying for Permit: Name of Admoitted AUNrt for this projW:
ownees IIWM 9 Address:
PO ox Vo
Phone Number,91l )'lam' Gq 15
AWWS Mei #Address:
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Phone Numb
I certify that I have audxxtted the agent listed above to ad on my bell for the purpose of applying
au cAMA Permits neoessary to install or oonstruct tF km*V ( ,):
For my property IoaaW at
This certification is vW thru (deft)
P"Ipsrty Owner J14r111101 s Dole

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