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CERTIFICATE OF EXEMPTION
FROM REQUIRING A LAMA PERMIT T�T� 02
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
licant Name A LtA /� C Phone Number
ress i-
CtPct yj J:e Lc ! �Q Lt, ,'.State 6L Zip
(County, State Road, W ter Bodyetc.)
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pe and Dimensions of Project
proposed project to be located and constructed as described
ve is hereby certified as exempt from the CAMA permit
jirement pursuant to 15 NCAC 7K This exemption
;AMA permit requirements does not alleviate the necessity of
r obtaining other State, Federal or Local authorization.
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This certification of exemption from requiring a CAMA
valid for 90 dajs from the date of issuance. Following ex
a re-examination of the project and project site may be r
to continue this certification.
KETCH (SCALE:
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North Carolina Department of Environment and Natural Resources
Division of Coastal Managernerii
Beverly Eaves Perdue Jaynes H. Gregson Dee Freemal
Governor Director Secretary
AGENT AUTHORIZATION FORM
Date:
Name
of Property Owner /Applying for Permit: Flame of Authorized Agent for this prrojject:
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Owner's Mailing Address:
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19/9 5/vq,-
( cc�h�(e 6e� c _ IN '7�V?
Phone Number &X 25"A ?D L
Agent's Mailing Address:
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Phone Ngm_bef (9/0 t 9�2 —3W2 S
I certify that i have authorized the agent listed above to act on my behalf, for the purpose of applying
for and obtaining all C/AMA Permits necessary to install or construct the following (actiJity):
I��'� / mil) GilrfYl�r:,c� Alt'✓ .�b✓rFc� 61�eDWrat`� 4S�Oei�firon
(my property located) at ( ter �lrLk �'+<' Sic6rryCSfch
ice rct 5&hz
This certification is valid that (date) .1 2 ./
Property Owner Signature Date
t 27 fiar&ai Drive EA., fflvt nglon, NC 26405 D o th Carotiiia
Phone: 910.795•72WFAY, 9IG-3953964 Vatmnally
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