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CERTIFICATE OF EXEMPTION
FROM REQUIRING A LAMA PERMIT 010
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licant Name
ress - -tt
ect Location
as authorized by the State of North Carolina,
Department of Environment and Natural Resources and the Coastal Resources ion Wion
in `an area of environmental concern pursuant to 15 NCAC Subchapter 7K (G �C Z5? . G'31
16hh /Vi LU1L Phone Number IIIU 6f495
and Dimensions of Project
iroposed project to be located and constructed as described This certification of exemption from requiring a CAMA pe
is hereby certified as exempt from the CAMA permit valid for 90 days from the date of issuance. Following expi
-ement pursuant to 15 NCAC 7K . This exemption a re-examination of the project and project site may be ne,
AMA permit requirements does not alleviate the necessity of to continue this certification.
obtaining other State, Federal or Local authorization.
ETCH (SCALE:
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North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Pat McC rory•
Governor
Braxton C Da, John E Skvarla, ill
Director Secretary
AGENT AUTHORIZATION FORMA ENT AUTHORIZATION FORM
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NCDETIR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Pat McCrory
Governor
Date: `7'j8'1T
Braxton C Da% John E Skvarla, III
Director Secretary
Name of PropertOwner Applying for Permit: a of A razed � gent r this project
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Owner's Mailing Address: Agent': ailin Ad ss.
�713 Jvc H� /v ltl }t��(1r J�
Phone Number 77 Phone Number(6 ) S7�f t. _
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 neces§ary to install -or construct the following (activity):
For my property located at L o,r rl r-,- Tme C
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This certification is valid thru (date) - y
Property Owner Signature Date

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