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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
Address �-5 /o
City
Phone # (9/�) vY
Authorized Agent
Type of Project
Description of Activity:
l .,;. Q --r
Notes or special
conditions:
Owner's Name (print)
Signa re (owner or agent)
?IZT p: :3111 . �: .—X K
RECEIVED
❑ MAINTENANCE AND IRMWRILMINGTON, NC
Permit# IIIN 1 2005
Date previous
permit issued
Project Location Information n
Street Address
Adj. Water Body
AEC ❑ CS ❑ OE ❑ HH ❑ IH
L O Signa ure
S/ Z 1Zo S
Issuance date exp. bate
Oak Island Development Services — 518 Yaupon Drive — Oak Island NC 28465 — 910-278-5024