Mishoe, Mike

®IJ CAMA / F11 DREDGE & FILL w' µ No. 75229 A B C D
GENERAL PERMIT s ' Previous permit#
F-JNew ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
❑ Rulesattached.
Applicant Name I i ( Project Location: County
Address 1 ' , Street Address/ State Road/ Lot #(s)
City �; ��
P-_-d_:..
State-----ZIP
Phone # O
E-Mail -_
Authorized Agent
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Affected CCW
DEW
7PTA DES
❑PTS
AEC(s): ❑ OEA
❑ HHF
11 IH ❑ UBA
❑ N/A
L PWS:
ORW: yes / no
PNA
yes / no
Type of Project/ Activity
Pier
Fixe
Floa
Fing
Groi
Bulk
Basi
Boat
Boat
Beac
Oth
shor
SAV
Mor:
Phot
Waiv
Subdivision
City__ ZIP
Phone # ( ) River Basin
Adj. Wtr. Body IT i '` _ _ __ _ (nat /man /unkn)
Closest Maj. Wtr. Body -
(Scale:__,_.
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ing Platform(s)
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A building permit may be required by:
( Note Local Planning jurisdiction)
Notes/ Special Conditions
Agent or Applicant Printed Name
❑ See note on back regarding River -Basin rules.
Permit Officer's Printed
Signature•'Please read compliance statement onback ofperm t'*t` / Signatures
Application Fee(s) .Check# Issuing Date - Expiration Da>�

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permitp S �I
I � 1 � � (�
Mailing Address: )\oU 1
New P oI'fiAj c ��S w
Phone Number: V 3 1 % V 7 y b e)
Email Address: ill t SV OQ � Mt K« C .\/a., �00,
I certify that I have authorized _�j t NAN / 7C) /k)QF_
Contractor
to act on my behalf, for the purpose of applying for and �lobtaining all CAMA permits
necessary for the following proposed development: FC�.0 I I Ja A,,e 3,,c K
ej \0y 0tir ,"Ne
at my property located at t �l N'Q u/�/ j a �i S 7 v
in L VA<J_e i County.
I furthermore certify that I am authorized to grant, and do in fact grant permission to
Division of Coastal Management staff, the Local Permit Officer and their agents to enter
on the aforementioned lands in connection with evaluating information related to this
permit application.
Property Ow er Inf ation:
Signature
M,sk"'e
Print or Type Name
I�UAX OwN-e
Title
Date
This certification is valid through

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