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CERTIFICATION OF EXEMPTION
FROM REQUIRING A CAMA PERMIT
as authorized by the State of North Carolina,
Department of Environment, Health, and Natural Resources and the Coastal Resources Commission
in an area of environmental concern pursuant to 15 NCAC Subchapter 7K,02fl3.
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ilicantN�a1me IvIIL�t(td LQIViSSa tjYvlh C10 Mbrrh� Phone Number i(0•y�k3.;
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ct Location (County, State Road, Water Body, etc.;
C' 61'10 belI iA IS
and Dimensions of Project
b proposed project to be located and constructed as described
)ve is hereby certified as exempt from the CAMA permit re-
rement pursuant to 15 NCAC 7K .0203. This exemption to
MA permit requirements does not alleviate the necessity of
jr obtaining any other State, Federal, or Local authorization.
This certification of exemption from requiring a CAMA F
valid for 90 days from the date of issuance. Following ex
a re-examination of the project and project site may be ne
to continue this certification.
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North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue James H. 6regson Dee Freeman
Governor Weector Secretary
AGENT AUTHORIZATION FORM
Date:
Name
91�of Property Owner Applying for Permit: Name of Authorized Agent for this project:
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Owner's Mailing Address: _
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Phone Number d IO) i/ Z( 3 --1'1y '3
Agent's Mailing Address:
Phone Numtmer ���� 4W -- 3 4= 2- 5
I certify that 1 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):
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(my property located) at 7 /�i d11 �'G S f ��•1 Jr:S/ l z'fc-,�_ VC
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This certification is valid th (date) _T J f 2-
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P i le
Property Owner Signature Date
127 Cardnal [love ExL, Mir bgforG NC 28405 N fle ©lina
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