02204D - Stone

a
r
�licant Name
ject Location
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 mission
in an area of environmental concern pursuant to 15 NCAC Subchapter 7K J,
✓AVIS DIIk Y't %.A(ItVYYII (rA�aVA(� (, Nk PhoneNur er ` Ib 3 �
e and Dimensions of Project
)roposed project to be located and constructed as described
e is hereby certified as exempt froM the CAMA permit
rement pursuant to 15 NCAC 7K . t^, ,?,. 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 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.
,ETCH (SCALE:
(

v t ;tip
P� A,x L
% czI)rt
t-4VS-A--

5/2013 14:13 FA.X
Z001
-
North Carolina Department of Envirompt and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue James H. Gregson
Governor Dk tar
Dee Freema
Secretai
AGENT AUTHORIZATION FORM
Date: q1- t�
Name of Property Owner Applying for Permit: Name of Authoriz d Agent for this project:
Owner's Mailing Address:
Phone Number L9M
Agent's Mailing Address:
F4& 2—
Phone. N umber
I certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
for and obtaining all CAMA Permits necessary to install or construct the following (activity):
Q,m�ve �� �,Qnc,�, � Ank rPb �►�� w� (c,.,�e, , 14ar1rP
(my property located) at rI cec".1 e. E ns.(-_
This certification is v ' thru (date)
r
Property Owner Signature
ate
Etoz s o -inr
....,... AAI^n