01420D - Britt

CERTIFICATE OF EXEMPTION
FROM REQUIRING A LAMA PERMIT 01,
as authorized by the State of North Carolina,
Department of Environment and Natural Resources and the Coastal Resources Commission
in an area of environmental concern pursuant to 15 NCAC Subchapter 7K u i' . t 11U)
)licant Name C �C((� �' f-' o f U� �A6kl 1.,G1+ t. Phone Number` 1
dress
i State NZ Zip 22
eject Location (County, State Road, Water Body, etc.) 01 ct
�4 c nAA U1 l k/Vj[►r
)lU
>e and Dimensions of Project
fi /.i 1t i, r 10-r1c v", 1 "'Im t'3 -J X I „ L
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 NI`< . This exemption
AMA permit requirements does not alleviate the necessity of
obtaining 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 exr
a re-examination of the project and project site may be ni
to continue this certification.
<ETCH (SCALE.-
Iux1�
Ft.ok►T
ell
t)( 66' om
C ►kiT NNn' Sap
�r'
NLA
x,E c�Mnr�

2015 1:05AM HP Fax page 2
NoM Carolina Departtment of En*cmment and Natural Resourm
Division of -co8"-mXkVWWd
Be" Eaves Perdue '.lames K Greg n Doe Re
Governor E k�ft Sec
AGENT AUTHORISATION FORM
Datej 0
Nrarre of P Ily rA for Permit: Name of Autlho���s for V* project:
1
= .
No is MsMng Address: .7 tc1
wRr4/4 ;.
Phan Number M
I certify tt�at.1 have authorized the agent listed_abova to act on my behalf, far the purpose of app"V
for and obtairing all CAMA PermitVtecesaVy to install or construct the kAowkV (activity):
Amy Property toraated) at
This ceriffication is valid thru (date)
Owner Sytnstum Dime

/ U/

1 2015 1:05AM HP Fax page 1
® C
YNI, A��y
s