01617D - Pope

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CERTIFICATE OF EXEMPTION
FROM REQUIRING A LAMA PERMIT TNT? Oil
as authorized by the State of North Carolina,
Department of Environment and Natural Resources and the Coastal Resources Co mission
in an area of environmental concern pursuant to 15 NCAC Subchapter 71Ci (� N
>licant Name kv1 U Ci Phone Number S �tfl
ire 1 Gi
�i r\A nn State _ 7in
le and Dimensions of Project
proposed project to be located and constructed as described
e is hereby certified as exempt from tie CAMA permit
rement pursuant to 15 NCAC 7K .!' I ( •��,,. 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 exf
a re-examination of the project and project site may be nE
to continue this certification.
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North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Braxton C Davis John E Skvarla. Ill
Director Secretary
AGENT AUTHORIZATION FORM AGENT AUTHORIZATION FuKm
Date — - 15
Name o Property Ow r A lying for Permit Name of Authorized Agent for this project
Owner's Mailing Address
Phone Number (3�_�
Agent's Mailing Address-
�y`rrce IU��S�VtAC,�41
&/E&� t e SiJ
n rfq L�t_1re,� n�,c,y69
Phone Number Lrfl.QJS_`�(gr�1��.
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I certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
for and obtaining all CAMA Permits necessary to install or construct the following (activity):
For my property located at �., , f tom, n+ IS4yek- (rete► 1 S(F - 'ktu 6 . ItiC. Ze%�
This 6rtifica n is valid te) 11 t r1 + __ (�-1 -
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Property Ore( r Signature Date
Ir C nx Cmve Exi ., Wii "RVOn NC 28405
Phone 91 7% 7215 FAX 910-396,3964 Uuemel waw ncroast�m�agemen! nE!

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