01633D - Meyers

CERTIFICATE OF EXEMPTION
FROM REQUIRING A LAMA PERMIT - Oil
as authorized by the State of North Carolina,
Department of Environment and Natural Resources and the Coastal Resources Co missio `
in an area of environmental concern pursuant to 15 NCAC Subchapter 7K
4icant Name a Y Phone Numbe , 10 �1i1r1�
Ire
St to Zip
jecct Lo aTtion (County, Slate Road, Water sody, etc.) a.
AhV� ✓n 1J `rk%e�-�- 0 ai'� IM it In - LA /� /a 0 0 n /I 1 v1 n A ,.Ln
e and Dimensions of Project V n,na
)roposed project to be located and constructed as described
is hereby certified as exempt frgt, e CAMA permit
rement pursuant to 15 NCAC 7K t))II This exemption
kMA 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 exp
a re-examination of the project and project site may be ne
to continue this certification.
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NCDETIR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
;Crory Braxton C. Davis John E. Skvarla, III
rnor Director Secretary
AGENT AUTHORIZATION FORM AGENT AUTHORIZATION FUKM
e of Property Owner Apprying Tor rermn:
7 mod`(
errs Mailing Address:
21,J.
`150
ie Number 03.) c'� 6 ( - ) (D D
Name oT AutnoriZea Agent Tor ims
Agent's Mailing Address:
Al �l
Phone NumiLm. (G S-7q
iifv that I have authorized the agent listed above to act on my behalf, for the purpose of applying
nd obtaining all CAMA Permits necessary to install or construct the following (activity):
SAC_
my property located at ��
certification is valid thru (date)
Property Owner W9nature Date

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