Skpper

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.
icant Name Phone Number
'ess 1 14 7C tr' > .
State Zip 1�
Dct Location (County, State Road, Water Body, etc.)
and Dimensions of Project i L C-,i All i it h
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)roposed project to be located and constructed as described This certification of exemption from requiring a CAMA per
e is hereby certified as exempt from the CAMA permit re- valid for 90 days from the date of issuance. Following expir
ment pursuant to 15 NCAC 7K .0203. This exemption to a re-examination of the project and project site may be nece
A permit requirements does not alleviate the necessity of to continue this certification.
obtaining any other State, Federal, or Local authorization.

overly Eaves Perdue
)vernor
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
James H. Gregson
Director
Dee Freeman
Secretary
AGENT AUTHORIZATION FORM
Date: /a.- / J,— a D/O
me of Property Owner Applying for Permit: Name of Autgorized Agent for this project:
1071/
mer's Mailing Address:
okyp
lone Number( )O) 67161--Iig'V— & 75;�el
Agent's Maili g Address:
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v �d T P�T 5r
13LI�j0 YVC
Phone Number (9m ) "-?, �03a
: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 ,W(
his certification is valid thru (date)
Property Owner Signature Date

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