Skipper

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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 .0203.
'cant Name kt7r(Lt'l S 'fit 12PQ. '0 J kT1- V\1 A-60 -Q< Phone Number "� � O -(ell -3(
ess No0off2FST Cl2
State iN t, Zip . 2 SA
act Location (County, State Noad, Water Body, etc.) 120E L. )[A-C wr ;;& . DA i,
-45tnicf it, Tom{. s l.Jr & 101yy
and Dimensions of Project (ZS F-y gill_-y-�
iroposed project to be located and constructed as described
a is hereby certified as exempt from the CAMA permit re-
ment pursuant to 15 NCAC 7K .0203. This exemption to
A permit requirements does not alleviate the necessity of
Dbtaining any other State, Federal, or Local authorization.
This certification of exemption from requiring a CAMA per
valid for 90 days from the date of issuance. Following expir
a re-examination of the project and project site may be nece
to continue this certification.
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CERTIFICATION OF EXEMPTION
r - rro
ioeUSoU
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 .0203.
Applicant Name C,kll�t ��5 �f�t i�1� {'� Phone Number A Its i G -75 -Z-M -
Address 1111 Z G tZ.
City -r i ti State V L Zip
Project Location (County, State Road, Water Body, etc.)
tip( i? DQ ,� l ;b t I >;ti' UL a i'C iL
Type and Dimensions of Project I NS-i1k �� Xic" �+'�� ILON16 t�u��N � ►�:%�� c1� �
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The proposed project to be located and constructed as described
This coy ication of exemption from requiring a CALM permit is
above is hereby certified as exempt tro-n the CAMA permit re-
valid for 90 days from the date of issuance. Following expiration,
quirement pursuant to 15 NCAC 7K .0203. This exemption to
a re-examination of the project and project site maybe necessary
CAMA permit requirements does not alleviate the necessity of
to continue this certification.
your obtaining any other State, Federal, or Local authorization.
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3r 12 2012 1:10PM HP LASERJET FAX 91027BG129 p.2
N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date
Name of Property Owner Applying for Permit:
C.h 4e-a S1e.e(c
Mailing Address:
49-A 4 1Jj9 cve,3 f Da
Cc,3fk , /VC-
T certifv that I have authorized (agent) 1)efrt-Ky W1�6evJto act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity)�r
at (my property located at) /�d4 `%fir f l3r+wl %S14 N�
This certification is valid thru (date)
Property Owner Signature
Date