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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.
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cant Name 209/�/C Doi t 0 r `i 1G �ALu Cr ti 4 Phone Number
ass f, D. 13,1 u 9 Q k
ct Location
and Dimensions of Project L C - - /�✓ �
roposed project to be located and constructed as described
is hereby certified as exempt from the CAMA permit re-
nent pursuant to 15 NCAC 7K .0203. This exemption to
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 expiry
a re-examination of the project and project site may be nece:
to continue this certification.
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AAEM WA
North Carolina Dgmrtmem of Environment and Natural Resources
Division of Coastal Management
&wly Eaves Perdue James H. Goa Dee Freeman
Governor Dkw" Secretary
AGENT AUTHORIZATION FORM
Date: 2-
Name of Property Owner Applying for Permit
Mailing Address:
Phone Number: t3�1 9oY �ooa
I certify that I have authorized (agent) L el /— U CJ' to act on my
behalf. for the purpose of applying for and obtaining all CAMA Permits necessary to install or
construct (activity) i"�,0�.�
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at (my property located at) /�S`� .%.g. ��.�.(, l�o%��r 6��.�c� /61-
This cerfiftcation is valid thru (date) &l ��� -2 0
Property Owner Signature

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