01607D - Stone

icant Name
,ess i,1'f I
CERTIFICATE OF EXEMPTION Pd
FROM REQUIRING A LAMA PERMIT
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as authorized by the State of North Carolina,
Department of Environment and Natural Resources and the Coastal ResourcesoOmission
in an area of1ennvironmental concern pursuant to 15 NCAC Subchapter 7K, / p
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Location, (County,
and Dimensions of Project
Road, Water Body, etc.) [!:iv`u
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roposed project to be located and constructed as described
is hereby certified as exempt fr m the CAMA permit
ement pursuant to 15 NCAC 7K ()I �z . This exemption
,MA permit requirements does not alleviate the necessity of
)btaining other State, Federal or Local authorization.
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This certification of exemption from requiring a CAMA pe
valid for 90 days from the date of issuance. Following expi
a re-examination of the project and project site may be nec
to continue this certification.
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J1Coastal Management
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C�.�tStACY
AGENT AUTHORIZATION FORM AGENT AUTHORIZATION FUKM
Date:
Name of Property Owner Applying for Permit: Name of Authorized Agent for this project:
Owner's Mailing Address:
Phone Number H I o ) _
Agent's Mailing Address:
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Phone Number �O�S
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 y — "
This certification is valid thru (date)
Property Owner Signature Date

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