Fauver

' T 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 '4�1-4661 A4VC1? !e Vi'VNv_/yoLde'v Phone Number`��
Dsssyy/ -Slx o,e,rS Ro,#c!
� . State ni C Zip
ct Location (County, State Road, Water Body, etc.) 10 4 d aC.P -W �u
and Di
,roposed project to be located and constructed as described
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.
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.
=TCH (SCALE:
7 n Gn IV. S...9.A

11 19108424798 8424798 p.1
A�
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
�ver;y Eaves Perdue James H. Gregson Dee � eeman
overnor Drecicr Secretari
AGENT AUTHORIZJaTION FORM
Date: - r
ime rof Property Owner Applying for Permit: Name of Authorized Agent for this p7o}ect:
wner's Mailing Address:
U'4't til,X tot{
'hone Number��t`i)
Agent's Mailing Address: -1 r
- l
Phone Number di 0 `f Y 3
certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
'or and obtaining all CANIA Permits necessary to install or construct the following (activgy): {
2 r r
(my progeny located) at cX °
This certification is valid thru (date) '�_ p
Property Owner Signature Date

11 19108424798
8424798