02227D - Schilawski

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CERTIFICATE OF EXEMPTION
FROM REQUIRING A CAMA PERMIT 022
as authorized by the State of North Carolina,
Department of Environment and Natural Resources and the Coastal Resource Commission
in an area of environmental concern pursuant to 15 NCAC Subchapter 7K0UO3
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licant Name / V , i aW IU Phone Number' N G
cr.�/fT_. i +T _
ect Location (County, State oad, Water Body, etc.
1/-et 4 (A A t K r u-tt Ol M G1,>n - W
and Dimensions of Project
)roposed project to be located and constructed as described
is hereby certified as exempt from the CAMA permit
-ement pursuant to 15 NCAC 7K . ('�� l72 . This exemption
AMA permit requirements does not alleviate the necessity of
obtaining other State, Federal or Local authorization.
This certification of exemption from requiring a CAMA pE
valid for 90 days from the date of issuance. Following expi
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
t McCrory Braxton C. Davis
iovemor Director
John E. Skvarla,
Secretary
AGENT AUTHORIZATION FORM AGENT AUTHORIZATION FUKM
Date: .'u^fe //, d-11-
ne of Property Owner Applying for Permit: Name of Authorized Agent for this project:
!/c-#,# G C. 5'4-Ii/c.A W 5 W Cak-t-6 Goal STA-Le-1711atl/
ier's Mailing Address:
'od 8 �c5A5/linl47�� STREET'
,ne Number (9/9) 41aP9-0is 7
(9/9) 17IIa - Y-7(a (.
Agent's Mailing Address:
(k-112 &g dU Ur 5W
Phone Number
rtify 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):
Ft,,047-i,J4 Val- r A+," 90 LSD 4A7-6
my property located at /4A V fy-R1fir4 :5-f 8£*r-N
> certification is valid thru (date)
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Property Owner Signature
Date

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■ Complete items 1, 2, and 3. Also complete
item 4 if Restricted Delivery is desired.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
1. Article Addressed to:
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j/Slgnat re
❑ Agent
❑ Addre
Received by ( Printed Name) C. D e f I
D. Is delivery address different from item Y
If YES, enter delivery address bG G No
3. Service Type
J4-6ertified Mail ❑ Express Mail
❑ Registered Return Receipt for Merchandise
❑ Insured Mail ❑ C.O.D.
4. Restricted Delivery? (Extra Fee) ❑ Yes
2. Article Number 2 912 8782
(Transfer from service lat 7013 3020 0001 —
PS Form 3811, February 2004
Domestic Return Receipt 10259"2-Wl540
U.S. Postal Service..,
CERTIFIED MAIL,, RECEIPT
(Domestic Mail Only; No Insurance Coverage Provided) -■
Postage
Certified Fee
Return Receipt Fee
?ndorsement Required)
Restricted Delivery Fee
?ndorsement Required)
Total Postage & Fees
$
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Restricted Delivery Fee
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C3 Street, Apt. No.; �------PO Box N--
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Ronnie Smith