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cant Name
CERTIFICATE OF EXEMPTION
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 Resourcei Commission
in an area of environmental concern pursuant to 15 NCAC Subchapter 7K,
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ject Location (County, State Road, Water Body, etc.)
and Dimensions of Project
proposed project to be located and constructed as described
e is hereby certified as exempt from the CAMA permit
irement pursuant to 15 NCAC 7K � 1 `, (i' . This exemption
AMA permit requirements does not alleviate the necessity of
obtaining other State, Federal or Local authorization.
State
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This certification of exemption from requiring a CAMA
valid for 90 days from the date of issuance. Following ex
a re-examination of the project and project site may be r
to continue this certification.
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C ER`l lFICATE I
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as :auttarizecf by tiie kite of Nord
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F EXEMPTION
:AMA PERM11' ` 1
ural Resources and the i pastal Resource Commission
puiS9dil')t to I S NChC Subchapter 7K �.. ire%. .
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I itt: I)ru[K)SCA t)JUjet t to bC IU' ;itt,f and con>u'uCtrd as des iLg<1
I IHs certificatkxt of exemption from re0lring a CAMA pert)
above Is lieleby ct.tkifilyd ;ii rx�illpt frQrrt the 'AMA rli)it
v:did for 90 days from the date of Issuance. Following expira
rrclultt�nu nt pttrsu.1ltt to 15 N('A(- I K r Cry 3 .. ml$ exell clot) a re"e)(,alnination of the project and project site may be nece
to ('AMA petillk I-Plue'ltetrts doer not alleviate tine tneces IV of to culstlnue this certification.
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NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
'at McCrory Braxton C. Davis John E. Skvada, III
Governor Director Secretary
AGENT AUTHORIZATION FARM AGENT AUTHORIZATION FURM
Date: S—ZZ -1 `-�
e pf Property Owner /Applying for Permit
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wrr's Mailing Ares
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lone Number ('706
Name of Authorized Agent for this project:
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d F L� i
ent's Mailing Add
Phone Number
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:ertify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
r and obtaining all CAMA Permits necessary to install or construct the following (activity):
Dr my property located at
his ation is valid thru (date)
Property Owner Signature Date

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