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CERTIFICATE OF EXEMPTION
FROM REQUIRING A LAMA PERMIT
as authorized by the State of North Carolina,
Department of Environment and Natural Resources and the Coastal Resources fission
in an area of environmental concern pursuant to 15 NCAC Subchapter 7K
Acant Name
cress ( A
fie and Dimensions of Project
proposed project to be located and constructed as described
e is hereby certified as exempt fr,Q e CAMA permit
rement pursuant to 15 NCAC 7K %� . This exemption
6,MA permit requirements does not alleviate the necessity of
obtaining other State, Federal or Local authorization.
011
Phone Number qjL. S�Ojq
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.
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CERTIFICATE OF EXEMPTION
FROM REQUIRING A CAMA PERMIT N° 017t'
as authorized by the State of North Carolina, D
Department of Environment and Natural Resources and the Coastal Resources Ission
In an area of environmental concern pursuant to 15 NCAC Subchapter 71K
1pplicant N me �_NlfdY fJ_ r1'�l1tG&1%Ph Phone Number
addresslj,,(—_YYall�_.
pity -- - A.Yi�Y�,�------ - ---- __ —� ate M Pr - - Zip
rotect LocTtion (County, State Road, Water Body, etc.) If
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•• andDimensions of •
ie proposed project to be located and constructed as described
rove is hereby certified as exempt fr��� e CAMA permit
quirement pursuant to 15 NCAC 7K t V1 V� . This exemption
CAMA permit requirements does not alleviate the necessity of
nrr obtaining other State, Federal or Local authorization.
This certification of exemption from requiring a CAMA pem
valid for 90 days from the date of Issuance. Following expirai
a re-examination of the project and project site may be neces
to continue this certification.
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N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date
Name of Property Owner Applying for Permit:
h,07
Mailing Address:
I certify that I have authorized (agent) _ tom//I / E�11S to act on my
behalf, for the purpose of applying for and obtaining all CA -MA Permits necessary to
install or construct (activity)
at (my property located at) � � Gj j�Z'%1 �l C� �'� �� �%e kx (:-
This certification is valid thru (date) � f if/y
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Property Owner Signature
WAWA
Date

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