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North Carolina DePEtnertt of Environment and Natural Resources
Division of Coastal Managemen'
Bever,y Eases Perdue .games H. Gregs3n Dlee Freeman
Govemor Cvecicr Sacretar/
AGENT AUTHORIZATION FORN".
Date:
Name of Property Owner Applying fo- Permit: ?dame of Authorized Agent for this project:
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Owner's Mailing Address:
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Phone Nurrber f� t`I
Agents Mailing Address:
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Phone Number L�9f c 1 •- <� 1�
I certify that I have authorized the agent listed above to act on my behalf, for the purpose of appl fing
for and obtainirg ar GAN 4 Permits necessary to install or construct the fcliowing (apt°vit):
property located) at
This certification is valid thru (date)
Property Owner Signature Date

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=efa..enced p=ope__v. '."_e �a�-, a.._, sit �o the abcve-
descr+Ibea tc me a� j'=yua_ aF;,-i'n5 nor = De --Lit teas
shown on the attaca=d drawl
t:.ey tre proposing. K des ES Lh& de sd, op e:
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sar^u:3 proYdEd w.t tr letter. `ng �.4tt dimftnsz.ors,
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heY y cerr L. that I o`vn property ad ` jacent to
rntereaced Property- The ind.-vidu&2 awl � , _„_ he above-
descr d �o this the as shown on the attached- draw= pe�.i; i'1as
they are pd17'J k dC5Cr1,Dtlpn or d=3Wl, r sirq. 9 deve? giant
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e provided with this 1 e th dimensions.,
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IC Division of Coastal h!9t, Habitat Impact Computer Sleet
)plirant. V M&v Permit #
ate:
t1
ascribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
and in your Habitat code sheet.
ibitat 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)
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 ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

FOR
LIGHTHOUSE MARINE CONSTRUCTION INC
PO BOX 2532
SURF CITY NC 28445-0028
Li=C( l
PAY DATE
THE
OR �i j C n �
ORDER OF_ o/
n > > s
Bankof America
ACH R/T 0630001 g8
- (on
II'00 4 10 ?n' 1:0 5 3000 19 61: 2 3 ?00 5 4 L 588 ?II■
L L A R S