Leavitt

CERTIFICATION OF EXEMPTION
k 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 ko6P2 L L . . r71 �f rf`Phone Number 7/n) TYO aa,
ress > // 4,/.
Sins e f Rcac 4 State N c Zip
ect Location (County, State Road, Water Body, etc.)
ano uimensions of Froiect
t k �-. c ., f' i
proposed 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
IA 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 expi
a re-examination of the project and project site may be nec(
to continue this certification.
ETCH (SCALE:
Chtip U

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management Dee Freema
3everly Eaves Perdue James H. Gregson Secretai
jDirector
overnor
AGENT AUTHORIZATION FORM
Date:
lame of Property Owner Applying for Permit:
Name of Authorized Agent for this project:
tt KIm L-. A Atn
owner's Mailing Address:
� rl �.A.-�� L ✓i' JE
Phone Number
Agent's Mailing Address:
I s��
�fol el,)
Phone Number 104 �,�'1 %' 331 V
I certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
for and obtaining all CAMA Permits necessary to install or construct the following (activity):
(my property located) at
This certification is valid thru (date)
Property Owner Signature Date