01632D - Smith

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CERTIFICATE OF EXEMPTION Q�1��
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 Resources Commission
in an area of environmental concern pursuant to 15 NCAC Subchapter 7K . cif 43 , 53U cNq �.
�n L1G., 14— 0o (-- �YXt (�E��YV( 11c�Phone Number IG O
e and Dimensions of Project 6 — A- A
)roposed project to be located and constructed as described
e is hereby certified as exempt from the CAMA permit
rement pursuant to 15 NCAC 7K _ 01 '2 . 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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AGENT AUTHORIZATION FORM AGENT AUTHORIZATION FORM
Date: / (' . 5
Name r perty Own t, Apply�g for Permit
Owner's Mailing Address:
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Phone Number Ems)
me of Authorized Agent for this project:
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Agent's fKailing Address:
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Phone Number (�) S-7 CC
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 Per it necess ry to install or construct the following (activity):
For my property located at

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