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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 1sA
Address
City b(!K
Phone #
Authorized Agent "&
Type of Project
Description of ctivity:
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Notes or special
conditions:
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Own is Name rint)
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ature (owner or agent)
HTAAINTEN E� �J1'�J,11 1y
Permit #
Date previo MAR 10 2005
permit issu
DIVISION OF
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" IvI/AIJAGEMENT
Project Location Information
Street Address�(i %vim
6 od- Kr S lug.-P
Adj. Water Body C
AEC ❑ CS R-bE ❑ HH ❑ IH
LPO Signature
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Issuance date exp. Date
Oak Island Development Services — 518 Yaupon Drive — Oak Island NC 28465 — 910-278-5024