Broglin

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CERTIFICATION OF EXEMPTION
FROM REQUIRING A CAMA PERMIT
as authorized by the State of North Carolina,
roll 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.
ilicant Name A L `n1.4l Phone Number (9/o)yid -�-
ress .
/ State v Zip 2 8
ect Location (County, State Road, Water Body, etc.) 0 _ a f 0
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e9.and Dimensions of Project
proposed project to be located and constructed as described
✓e is hereby certified as exempt from the CAMA permit re-
Dment pursuant to 15 NCAC 7K .0203. This exemption to
4A permit requirements does not alleviate the 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 exp'
a re-examination of the project and project site may be nec
to continue this certification.
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HCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue Jams H. Gregson
Governor Director
AGENT AUTHORIZATION FORM
Dates
Name of Property Owner Applying for Permit:
Owner's Mailing Address:
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Dee Freeman
Secretary
NameofAuthorized Agent forth is project:
Agent's Mailing Address:
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Phone Number C1 ro) "Lq 55:W Phone Number 04�—
i certify that I have authorized the agent listed above to act on my behalf, for the purpose of appiym
for and obtaining a[! LAMA Permits necessary to install or construct the following (activity):
_owwwr- 0 -F 6 �6teacQ
(my property located) at _ /(2 ? �Sv ��a�«-__�'l�L- P-�iL�v��� /L� 22
This certification is valid thru (date)
Property Owner Signature, Date