01604D - Island

licant 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 Resources Commission
in an area of environmental concern pursuant to 15 NCAC Subchapter 7K.,, 1 - ,
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Road, Water Body, etc.)
e and Dimensions of Project
imposed 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
kMA permit requirements does not alleviate the necessity of
obtaining other State, Federal or Local authorization.
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This certification of exemption from requiring a CAMA pf
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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NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
:,at McCrory Braxton C. Davis
Governor Director
John E. Skvarla, II
Secretary
AGENT AUTHORIZATION FORM AGENT AUTHORIZATION RV M
Date:
lame of Property Owner Applying for Perr lit: N me of Authorized Agent for this project:
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?wner's Mailing Address:
'hone Number ( %3),� Ll 9 i779
Agent's Mailing Address:
Phone Number 51 1v �
certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
or and obtaining all LAMA Permits necessary to install or construct the following (activity):
:or my property located at
This certification is valid thru (date)
t� t�iiU i�.•� �auu�er Date
f Property Owner Signature

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