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North, Carolina Cepaftment of Environment and Naturai Resources
Uivision of Coastal Managemert
6evafiy caves F due James H. Gregsor
Gcverrcr f MIC!or
i
i
Name of Propertl Owner
Owner's Mailing ddress
�d
Ids �
P-w i � l
Phone Number
AA"NT AUTHORIZATIQN FORM
Date. /a-1-)1
Dee Freeman
Secretary
yling for Permit, Name of Authorized Agent for tr,is project
'G W r-e v S L.s 41 �l 0�+, 0 1V�[i✓�i 7�t ``
/a
Agemi's Mailing Address'
D i3aIc ,� 3
120- 3 e s
1), () C� Phone Number aI0 e2h
t certify that I na Iauthorized the agent listed above to act on my behalf, for the purpose of applying
for and obfa�^ins Ii CiAMA Permits necessary to install or corstruct the 1`60% fng (activity) -
(my prop" io � at t"5�fiy►i1 lnpCv� This ificetion s valid thru (date) _
,17- 11
Proie y Owner Signature ^T Cate

plicant: !! l�`�i St`{0,�°L- S �C�/� Permit #:�
te:
scribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
nd in your Habitat code sheet.
)itat Name DISTURB TYPE
Choose One
TOTAL Sq. Ft.
(Applied for.
Disturbance total
includes any
anticipated
restoration or
temp impacts)
FINAL Sq. Ft.
(Anticipated final
disturbance.
Excludes any
restoration
and/or temp
impact amount)
TOTAL Feet
(Applied for.
Disturbance
total includes
any anticipated
restoration or
temp impacts)
FINAL Feet
(Anticipated final
disturbance.
Excludes any
restoration and/or
temp impact
amount)
r�
Dredge ❑ [IFill Both Other ❑
/
/ ;?W,
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

LIGHTHOUSE MARINE CONSTRUCTION INC
PO BOX 2532
SURF CITY NC 28445-0028
DATE
PAY
TO THE
ORDER OF /
tr�Lt6�) vv l/)
Bank of America
ACH R/T 0533000196 /
FOR
f II0004 2 5 3n' 1:0 5 3000 L 961: 2 3 70[
L
DOLLARS