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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.
plicant Name /a Phone Numbe
dress Y % oe&,
_4do-' 9c n State i ►' c Zip 2 S
ject Location (County, State Road, Water Body, etc.) /! i Sea c e 9 r To
e and Dimensions of Project A 44eZiC d oCA6', 2
a proposed project to be located and constructed as described This certification of exemption from requiring a CAMA F
Dve is hereby certified as exempt from the CAMA permit re- valid for 90 days from the date of issuance. Following exl
rement pursuant to 15 NCAC 7K .0203. This exemption to a re-examination of the project and project site may be ne
MA permit requirements does not alleviate the necessity of to continue this certification.
jr obtaining any other State, Federal, or Local authorization.
KETCH (SCALE:

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22-2010 16:51 From:
To:910 1946 9e13 P.1/1
C- DENR Resources
North Carolina Department of Environment and Natural
Division of Coastal Management
Beverly Eaves Perdue James H. Gregson
D
Governor irector
Dee Freeman
Secretary
AGENT AUTHORIZATION FORM
Date: — a 5- /D
�4ame of Property Owner Applying for Permit Name of Authorized Agent for this project:
Owner's Mailing Address'.
Phone Number
Agent's Mailing Address;
A L Jd ,D,P.s.u.),
6Z_
Phone Number — 9 �Z
I certify that 1 have authorized the agent listed above to act on my behalf, for the purpose of applying
t 't V
for and obtaining all CAMA Permits necessary to install or co\ w
struct the follo^ng (ac Zvi y;
This certification is valid thru (date)
Property Owner Signature Date