Paty, C.

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❑ MODIFICATION ❑ EXEMPTION D MAINTENANCE AND REPAIR
Town of Oak Island Permit # ' —
CAMA Minor Permit Office Date previous
As authorized by the State of North Carolina permit issued
per the Coastal Area Management Act of 1974
Applicant Name
Address
Citv
Phone #
Authorized Agent
Type of Project
Description of Activity:
Notes or special
conditions:
Owner's Name (Print)
Signature (owner or agent)
Project Location Information
Street Address -
Adj. Water Body
AEC ❑ CS o OE ❑ HH ❑ IH
LPO Signature
Issuance date exp. Date
Oak Island Development Services — 518 Yaupon Drive — Oak Island NC 28465 — 910-278-5024