Core Banks Club, LLC

®,WCAMAi<6REDGE & FILL NO. 75929 A B (C .: D
GENERAL PERMIT Previous permit#
]New' ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit iisss^^^uyyyed p
As authorized by the State of North Carolina, Department of Environmental Quality Eli 6 i
and the Coastal Resources Commission in an area o environent I concern pursuant to SA NCAC 1
Rulel attached.
Applicant Names C�;' Y, ( 1-fi n �> ��`"`� �` Project Location: County ` C1
Phone # WO ) ) J /-
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Affected ❑CW PEW UPfA DES ❑PTS
AEC(s): ❑OEA ❑HHF ❑IH ❑USA ❑N/A
❑ PWS:
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A building permit may be required by:
( Note Local Planning jurisdiction)
Notes/ Special Conditions
e' y I r
Agent or Applicant Printed Name
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Signature,'* Please read compliance statemento backof permit's'
Application Fee(s) Check #
❑ See note on back regarding River Basin rules.

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: GO/� IYJij/if C Z�b LG C
Mailing Address:
Phone Number:
Email Address:
I certify that I have authorized
2P, e� /Z�3S-/
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3J -- 232 - / %fS
to act on my behalf, for the purpose of applying for and obtaining all CAMAypermits /
necessary for the following proposed development:
at my property located at /;�s
in County.
1 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 Owner Information:
(% Signature�—�
✓z� hl Z, C . /g �Z 'y
Print or Type NanjV
Title
L
Date
This certification is valid through
RECEWS-0
Nov 12 , .
j)CM.MHD CITY