Indian Beach Fishing Pier Inc.

❑CAMA / ❑ DREDGE & FILL - r" ( No. 74442 A B C D
GENERAL PERMIT Previous permit#
17New ❑Modification ❑Complete Reissue []Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality i i -
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
,? El Rules atta�hed.
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Applicant Name
Address
City r c State 1 Il. ZIP i
Phone # (� �) 1�- ' �E-Mail
Authorized Agent k r I''i'i nci
Affected ❑CW FIEW ,NPTA ❑ES ❑PTS
AEC(s): OEA C HHF ❑ IH ❑ UBA ❑N/A
❑ PWS:
ORW: yes / no PNA yes /no
Project Location: County
Street Address/ State Road/ Lot #(s)
Subdivision
Phone # ( )
Adj. Wtr. Body l
Closest Maj. Wtr. Body -
ZIP__
River Basin
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�Agen[or Applicant Printed Name
Signature z- Please read compliance statement on back of permit" i
Application Fee(s) Check #
Permit Officer's Printed Name
Signature
Issuing Date Expiration Date

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. ` PLAN NO.
STREET ADDRESS: ' w apt `5 ch V
Please print: Ivaco'
Property Owner: —
Property Owner: Ltio
VP_c'G Cn
L.
PARCEL ID: 03o)q Q 6LP U �5 �lZSa,-V
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The undersigned, registered property owners of the above noted property, do hereby authorize
(Contractor / Agent)
(Name of consulting firm)
to act on my behalf and take all actions necessary for the processing, issuance and acceptance of
this permit or certification and any and all standard and special conditions attached.
Property Owner's Address (if different than property above):
Telephone: a"-:5d-354-3
SIGN
We hereby certify the above information submitted in this application is true and accurate to the
heat of our knowledge.
Authorized i at e1\ Kuthorized Signature
6
Date: u/23�/ Date: �Y /%