01788D - Williamson

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CERTIFICATE OF EXEMPTION
FROM REQUIRING A LAMA PERMIT T'' 0i"+
as authorized by the State of North Carolina,
Department of Environment and Natural Resources and the Coastal Resources, mmission
in an area of env'ronlmental concern pursuant to 15 NCAC Subchapter 7K �cl
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licant Name 1 I `1 C Phone Number $:TqC
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State Zip
ec ovation (Cou ty, State Road, Water Body, etc.)
a and Umensions of Project,-
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)roposed project to be located and constructed as described
is hereby certified as exempt from the CAMA permit
rement pursuant to 15 NCAC 7K . 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 pi
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
cCrory Braxton C. Davis John E. Skvarla, III
amor Director Secretary
AGENT AUTHORIZATION FORM AGENT AUTHORIZATION FuKm
Date: /D
of Property Owner Applying for Permit: N me of Authorized Agent for this project:
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-'s Mailing Address:
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Numberdw)
A ent's Mailin Address:
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Phone Number( �� ) �Q dq _
y that I have authorized the agent listed above to act on my behalf, for the purpose of applying
i obtaining all CAMA Permits necessary to install or construct the following (activity):
y property located at -3 ,
artification is valid thru (date
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Property Owner Signature Date

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