01502D - Passiales

plicant
CERTIFICATE OF EXEMPTION
FROM REQUIRING A LAMA PERMIT Qi
as authorized by the State of North Carolina,
Department of Environment and Natural Resources and the Coastal Resources omission
in an area of environmental concern pursuant to 15 NCAC Subchapter 7K bit
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:)e and Dimensions of Project ,� 1
proposed project to be located and constructed as described
✓e is hereby certified as exempt from the CAMA permit
drement pursuant to 15 NCAC 7K . 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 I
valid for 90 days from the date of issuance. Following ex
a re-examination of the project and project site may be n
to continue this certification.
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AGENT AUTHORIZATION FORM AGENT AUTHORIZATION FuKm
Date: ���/ F
me of PropertyO ner Applying for Permit Name of Authorized Agent for this project:
ner's Mailing Address:
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me Number (39
Agent's Mailing Address:
Phone Number
�rtify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
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in g all CAMA Permits necessary to install or construct the following (activity):
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my property located at �/_- ,� <<' l7l4 s f Xe'11-L, / /f%C- ,,2PerGX
certification is valid thru (date)
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ope Owner Signature Date

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