02208D - Island

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CERTIFICATE OF EXEMPTION
FROM REQUIRING A LAMA PERMIT T'`^ 024,
as authorized by the State of North Carolina,
Department of Environment and Natural Resources and the Coastal Resources Co mission
in an area of environmental concern pursuant to 15 NCAC Subchapter 7K 9 ( o 5--H .90
>licant Name ISIOAdPHnW Y Phone Number 4-3.2TI . 1i
tress b.
A UV, State Zip
ject Location (CountV, Stat oad, Water Bo etc.)
,A/n I1 i Lt 11A �� t1YYA�✓ I�- s _ T) I A iv��f V_�1Ji� 1 rt
e and Dimensions of Project
proposed project to be located and constructed as described
e is hereby certified as exempt from the CAMA permit
rement pursuant to 15 NCAC 7K ,P1 f 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.
;ETCH (SCALE:
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NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
gat McCrory Braxton C. Davis
Governor Director
John E. Skvarla, I
Secretary
AGENT AUTHORIZATION FORM AGENT AUTHORIZATION FuKm
Date: _ iq -1 D
3me of Property Owner Applying for Per it: N me of Authorized A ent for this project:
i
A i �arL {� , Ow�u ;soda "
Nner's Mailing Address:
P. 0. Aq a (an
a�5�a
lone NumberLlq-1-779
A ent's Mailing Address:
7��kCI0 �n
VWX 9WIN1111_
Phone NumberQ'
;ertify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
and obtaining all CAMA Permits necessary to install or construct the following (activity):
it my property located at
its certification is valid thru (date) n fi �_3 1 — aQ 1Ll
')C�roperty Owner Signa ure( °�aq2►' Date

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