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icant Name E
'ess /.3, 7T""
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;ct Location u
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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AA c h State
y, State Road, Water Body, etc. / O T Ro N
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and Dimensions of Project / P , is ,e- . o - ,c
iroposed project to be located and constructed as described
a is hereby certified as exempt from the CAMA permit re-
,nent pursuant to 15 NCAC 7K .0203. This exemption to
A permit requirements does not alleviate the necessity of
Dbtaining 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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NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
leverly Eaves Perdue James H. Gregson Dee Freen
governor Director Secret
AGENT AUTHORIZATION FORM
Date: /f — !::_)�
ame of
Property Owner Applying for Permit: N e of Auth1or* nt for this project:
iwner's Mailing Address: n
(� a ►— d �. JAY,
'hone Number
Agent's Mailing Address:
00
Phone Number
certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
or and obtaining all CAMA Permits necessary to install or construct the following (activity):
(my property located) at
This certification valid t 7(d)
Perty 0`w`4 Signature Date

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