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❑ MODIFICATION ❑ EXEMPTION
Town of Oak Island
CAMA Minor Permit Office
As authorized by the State of North Carolina
per the Coastal Area Management Act of 1974
Applicant Name 5 ,gol z
Address .s/lL /dEsr -54;�rU�
City Ae -,11cf—
Phone # ( ) � 7Y —yGa 9
Authorized Agent
Type of Project
Description of Activity:
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Notes or special
conditions:
Owner's Name (Print)
nature (owner or agent)
❑ MAINTENAMErAND REPAIR
Permit
Date p
permit
r)1%11 .,
UOASTai ""vN OF
Project Location PneoVAMENT
Street Address .5—/1 Z
Adj. WaterrrBBody
AEC H?, S ❑ OE ❑ HH ❑ IH
Signature
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Issuance date exp. Date
Oak Island Development Services — 518 Yaupon Drive — Oak Island NC 28465 — 910-278-5024