Mariners Cove

®❑CAMA / ❑ DREDGE & FILL O
,.. N. 78469 A a c D
GENERAL PERMIT Previous permit#
❑New ❑Modification []Complete ReisVW ❑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 I SA NCAC
LJ Rules attache
Applicant Name �� i i)�. �� _ pp Project Location: County 1
Address ( -L ; "x Street Address/ State Road/ Lot #(4)
( State 11 ZIP I `'" City' I l _ i, �.L J -
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j' I ��. Subdivision
Authorized Agent I `} 1.1(, j��city �
ZIP
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AEC(s): ❑OEA
❑ PWS
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Agent or Applicant Printed Name
Sg ature **Pel a read compliance statement on back of permit""
Application Fee(s) Check #
Expiration Date

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
CIA as Q rJ1,YS
Ma-n �r1 '.L=.tv��
Name of Property Owner Requesting Permit: kTi�E 32 (� `--oa. Q
Mailing Address.
Phone Number: Q� 1-( - /A13-5-c,(QI
Email Address: C�Cc_L4 0, ms�,, V \. C�
1 certify that I have authorized
1 Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CA1MA permits
necessary for the following proposed development: (S t .\C V'J.ShMeri P
at my property located at
in Q- P` County.
lY c,
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 Owner Information:
Signature
('IFRA G�clwltN
MW�Print or Type Name
—�
Title
Date
This certification is valid through �Zz /_L/ , ,in '0