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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.
licant Name 1--e nm C!LPhone Number �10
act Location (County, State Road, Water Body, etc.)
A 1. t rif t vet-- -h , - mi
and Dimensions of Project
)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 nol�ttJi6iethe necessity of
obtaining any other State, Federal, or Local authorization.
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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MCDENK.. - North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue James H. Gregson
Governor Director
De(
AGENT AUTHORIZATION FORM
Date: 'C'
Name of Authorized Agent for this project:
me of Pro a Owner Appl ing for Permit: .
r
Owner's Mailing Address: C
`-I i v
Phone Number%Sg�
Agent's Mailing Address:
� CQ-(A
Phone Number(
I certify that I have authorized the agent listed above to act on my behalf, for the purpose of applyinc
for and obtaining all CAMA Permits necessary to install, or construct the following (activity):
(my property located) at
Ur�nb
This•certification is valid thru (date)
,. — _ Date

16 CA
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