Palmer

CERTIFICATION OF EXEMPTION
_Y 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•.o; V 3
;ant Name
Nt � � Vet Phone Number
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ILL A'k
,,t Location ( unty, State Road Water Body, etc.) t�1tY�c t
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�oposed project to be located and constructed as described This certification of exemption from requiring a CAMA perr
is hereby certified as exempt from the LAMA permit re valid for 90 days from the date of issuance. Following expiry
nent pursuant to 15 NCAC 7K .0203. This exemption to a re-examination of the project and project site may be nece
% permit requirements does not alleviate the necessity of to continue this certification.
)btaining any other State, Federal, or Local authorization.
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NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue James H. Gregson
Governor Director
Dee Freemai
Secretar
AGENT AUTHORIZATION FORM
Date: —
lame of Property Owner Applying for Permit: Name of Authorized Agent for this project:
)wner's Mailing Address:
Agent's Mailing Address:
Rhone Number (%4 3"-q5;-1 6 Phone Number12(0)
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):
(my property located) at
This certification is valid thru (date)�—
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Property Owner Signature Date