01605D - Bowen

Acant Name
Dress. --�VU
CERTIFICATE OF EXEMPTION
FROM REQUIRING A LAMA PERMIT 0.
as authorized by the State of North Carolina,
Department of Environment and Natural Resources and the Coastal Resource�Commission
in an area of environmental concern pursuant to 15 NCAC Subchapter 7K-, 103 .
Phone Number gN5-"M905
Location (County, Stale Road, Water Body, etc.) i`�%151��L1 _ (;),�n+l
and Dimensions of Project ,n
proposed project to be located and constructed as described
e is hereby certified as exempt from the CAMA permit
irement pursuant to 15 NCAC 7K . This exemption
MA permit requirements does not alleviate the necessity of
obtaining other State, Federal or Local authorization.
This certification of exemption from requiring a CAMA
valid for 90 days from the date of issuance. Following ex
a re-examination of the project and project site may be r
to continue this certification.
KETCH (SCALE: = L C.)
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NCDENR
North Carolina Department of Environment and
Division of Coastal Management
at McCrory Braxton C. Davis
3ovemor Director
Natural Resources
John E. Skvarla,
Secretary
AGENT AUTHORIZATION FORM AGENT AUTHORIZATION FuKm
Date: � -�` ZZ I L I
me of Property Owner Apply
ingr Permit:
�Cb. 4
rner's Mailing Address:
34 C-(?-0644,E-P
one Number O16) — 7 * r
Name of Authorized Agent for this project:
Agent's Mailing Address:
Uv� ��Qch �; 5 �aj
U Qu I A T;S `e �3(Ad N
z�y(- y
Phone Number a L) 5-7
irtify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
and obtaining all CAMA Permits necessary to install or construct the following (activity):
my property located at 42,4C� C 0.6;f 4 S i ;
s certification is valid thru (date)
Property Owner Signature
Date

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2
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