Incet

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.,olYlg:�65
Vicant Name j Ale E
(dress 414,-Se
:y ,d e 7
Dject Location (Counter,
p and Dimensions of Project
i _ _ 9
lk�k'6
Road, Water Body, etc.) -fkc—
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e proposed project to be located and constructed as described
Dve is hereby certified as exempt from the CAMA permit re-
rement pursuant to 15 NCAC 7K .0203. This exemption to
,MA permit requirements does not alleviate the necessity of
jr obtaining any other State, Federal, or Local authorization.
State
Phone Number `16 T 7L
Zip 4
This certification of exemption from requiring a CAMA F
valid for 90 days from the date of issuance. Following ex
a re-examination of the project and project site may be ne
to continue this certification.
KETCH Li (SCALE: j\j
b'*r d

v,
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
verly Eaves Perdue James H. Gregson
)vernor Director
AGENT AUTHORIZATION FORM
Dee Freem,
Secreta
Date: aG
me of Property Owner Appl ing for Permit: Name of Authorized Agn
for this project:
5� m1`CI 7 nJI
�0 6 0 P/"� . %4�►��
mer's Mailing Address. � Agent's Mailing Address:
Ir
01)
lone Number (Cf/0) -I 0�' !�l
At
Phone Number l o
;ertify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
r and obtaining all CAMA Permits necessary to install or construct the following (activity):
ny property located) at
'his certification is valid thru (date)
'
P r
Property Owner Signature,,' �! Date