01418D - Toovatech

lican Name
ress
CERTIFICATE OF EXEMPTION
FROM REQUIRING A LAMA PERMIT
01-4
as authorized by the State of North Carolina,
Department of Environment and Natural Resources and the Coastal Resource{ Commission
in an area of environmengl concern pursuant to 15 NCAC Subchapter 7K• V% b T
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i'C1�1 U—� Cjc.St�P Vllhone Number 7.5Z y2 —d
and Dimensions of Project
iroposed project to be located and constructed as described
is hereby certified as exempt from the CAMA permit
-ement pursuant to 15 NCAC 7K . This exemption
,MA permit requirements does not alleviate the necessity of
)btaining other State, Federal or Local authorization.
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 nei
to continue this certification.
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N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date Aq I %
Name of Property Owner Applying for Permit:
Mailing Address:
7535 Summit Ridge Rd
Middleton, WI 53562
I certify that I have authorized (agent) 86 S q0jj;/JAn to act on m(g )Y
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity) S *R'/-A l� h
at (my property located at) 1 Lis ou oq-u
This certification is valid thru (date)
Property Owner Signature Date