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} CERTIFICATION OF EXEMPTION
-Y
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.
1icantName LON KO l'oQZe /Y Phone Number 1,9S)y%� c
Iress .2 " d > Ct
�„ , 1 -4 L..4 State S Zip 29
ject Location (County, State Roa Water Baody, etc.) /h e ,c-- -- a M
r
/.� i! O j'' !' j.'I% ,iy l 'Pf�/✓ y S t 2�f/JO 49 g 4o, � NJ ,, C C. H
e and Dimensions of Project 9 o C.
proposed project to be located and constructed as described
ie is hereby certified as exempt from the CAMA permit re-
:ment pursuant to 15 NCAC 7K .0203. This exemption to
4A permit requirements does not alleviate the necessity of
obtaining any other State, Federal, or Local authorization.
1
This certification of exemption from requiring a CAMA PE
valid for 90 days from the date of issuance. Following exp.
a re-examination of the project and project site may be nec
to continue this certification.
.ETCH (SCALE:
V�

ST I
KUM
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue James H. Gregson
Governor Director
Dee Fr(
Sep
AGENT AUTHORIZATION FORM
Date: 1
Name of Property Owner Applying for Permit: (Name of Authorized Agent `foor this project:
Owner's Mailing Address:
152�5�
Phone NumberY)�_�9
Agent's Mailing Address:
Ocsz� n3VAe��� L
2,C6 LI
Phone Number
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 necess
� .-, �\ (')�- bu10VAe-q-d
(my property located) at
This certification is valid thru
ary to install or construct the following (activity):
/o - /6 --/co
Date

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