69101D - CJS

CAMA / - DREDGE & FILL
-. EN ERAL PERMIT Previous permit # A B C �'
ew _Modification ❑Complete Reissue CPartial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environment and Natural Resources
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
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ElRules attached.
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yes / no
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V to App ccVi;Arinte'dd Name
Sig -.Wig Please read compliance statement on back of permit **
Ap cation Fee(s) Check #

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AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: LVC13L 1*-A1Ve41
Mailing Address: / �� _�IEj 111-zle-
�i�tis�
Phone Number:
Email Address:
3S7- �?5-= 0737
I certify that I have authorized /5// /�OW4 01
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
41e'1_ah�
at my property located at ��� ��� L �114,
e
in / ;'� j,. ; LLtC County.
/ 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:
f,
Signature
Print or Type Name
Title
Date
This certification is valid through / /.

U.S. Postal Service""
CERTIFIED MAIL° RECEIPT
Domestic Mail Only
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