Wilcox

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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.
icant Name f11-7tVN r
'ess .1 St-v f2
act Location (County, State Road, Water Body, etc.)
and Dimensions of Project tT I, L-)-�
>roposed project to be located and constructed as described
e 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
obtaining any other State, Federal, or Local authorization.
State
Phone Number `I IC 61 1 ) -
Zip Z
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This certification of exemption from requiring a CAMA pe
valid for 90 days from the date of issuance. Following expii
a re-examination of the project and project site may be necE
to continue this certification.
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N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date I
Name of Property Owner
Applying\ for Permit:
th Pi,t n + 1� i I� G o x
r
Mailing Address:
lot S 5�
Cn Masp L
h (agent) 1
I certify that I Have authorized (• g ) to act on my �l
behalfJor the purpose of applying for and obtaining
install or construct (activity)
at (my property located at)
CAMA Permits necessary to
This certification is valid thru (date) 6
/ /13
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