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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
r in an area of environmental concern pursuant to 15 NCAC Subchapter 7K .0203.
cant Name Ro iiv Phone Number
ess ,� S
State /✓ CZip -2
act Location (County, State Road, Water Body, etc.) �� t > 1117A✓
and Dimensions of (A
Project, r - o o
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rJ �� (S7`irC 0 yl' Av`
roposed project to be located and constructed as described
is hereby certified as exempt from the CAMA permit re-
pent pursuant to 15 NCAC 7K .0203. This exemption to
a permit requirements does not alleviate the necessity of
)btaining 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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North Carolina Department of Environment and Natural Resources
I�Jtvision of Coastal Management
Beverly Eaves Perdue James H. Gregson pee freeman
Governor Director Secretan
AGENT AUTHORIZATION FORM
Date: ?�
Name of Property Owner Applying for Permit: Name of Authorized Agent for this project: I
i/<
-miner's f�railin nvdress:
Phone NumberCo 1 67,V` 7 lAcq
Agent's Wailing Address:
Phonze %umver
i certify that I nave authoring the agent `:steel above to act -n rnY behaif, for the purpose of appiyir�W
"or and obtaining all LAMA Permits necessary to install or construct the foiloWing (activity',"
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