CG-4143 Application for Class 1 Private Aids to Navigation on Ar

APPLICATION FOR CLASS 1 PRIVATE AIDS TO
NAVIGATION ON ARTIFICIAL ISLANDS AND FIXED
STRUCTURES
(Please read instructions on page 2)

U.S. DEPARTMENT OF
HOMELAND SECURITY
U.S. COAST GUARD
CG-4143 (Rev. 6-04)

1. NAME AND ADDRESS (including zip code) OF CORPORATION
OR PERSON MAKING APPLICATION

OMB APPROVED
1625-0011

2. ACTION REQUESTED FOR PRIVATE AIDS TO NAVIGATION
A.

ESTABLISH AND MAINTAIN

E.

B.

CHANGE OWNERSHIP

F. DATE OF ACTION

C.

CHANGE EQUIPMENT

D.

MOVE

DISCONTINUE

3. POSITION
A. GENERAL LOCALITY AND GRID AREA

B. LATITUDE

C. LONGITUDE

D. BLOCK NUMBER

F. LEASE NUMBER

G. WELL NUMBER

E. SIGN

4. LIGHT
A. CHARACTERISTICS

COLOR

B. NUMBER INSTALLED

WHITE

C. ILLUMINANT (Check)
ELECTRICITY

RED
FLASH

SECONDS

ECLIPSE

D. HEIGHT ABOVE MEAN HIGH
WATER

GAS

OIL

OTHER (Specify)

SECONDS

E. VOLTS

G. INSIDE DIAMETER

F. AMPERES
LENS

H. CANDLEPOWER (If known)

GLOBE

5. FOG SIGNAL (Characteristic will be one two-second blast every twenty seconds)
A. CLASS

B. MANUFACTURED BY

C. MODEL NUMBER

A (2-Mile)
B (1/2-Mile)

6. STRUCTURE
A. COLOR

B. HEIGHT ABOVE MEAN HIGH WATER

C. DEPTH OF WATER BELOW MEAN LOW WATER

7. AUTHORIZED BY CORPS OF ENGINEERS, U.S. ARMY, PERMIT NO.
8. PERSON IN DIRECT CHARGE OF AID
A. NAME

C. ADDRESS

B. TELEPHONE NUMBER

9. The applicant agrees to save the Coast Guard harmless with respect to any claims that may result arising from the alleged
negligence of the operation of the approved aids.
Attached to this application are:
A.

LOCATION PLAT

D.

CERTIFICATE REQUIRED BY 33 CFR 67.10-1 (4)

B.

PRINT OF STRUCTURE

DATE

C.

AIDS TO NAVIGATION EQUIPMENT LIST

SIGNATURE

TITLE

FOR COAST GUARD USE
10. FROM:

Commander

Coast Guard District

A. THE ACTION DESCRIBED ABOVE IS

B. NOTICE TO MARINERS

APPROVED
APPROVED SUBJECT TO THE COMMENTS IN BLOCK 11 ON
REVERSE
C. CHARTS AFFECTED

E. DATE

WILL BE ISSUED
WILL NOT BE ISSUED
D. NAME OF AID(S)

F. SIGNATURE (By direction in accordance with 33 CFR 67)

PREVIOUS EDITION IS USABLE

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PAGE 2 OF CG-4143 (Rev. 6-04)

INSTRUCTIONS
1. The applicant will complete items 1 through 9.
2. Submit in triplicate to the Coast Guard District
Commander, Attach a location plat, print of the
structure showing positions of the aids, a complete
Aids to Navigation Equipment List, and when
establishing or changing a fog signal, the certificate
required by 33 CFR 67.10-1(4).

3. You may obtain from the Coast Guard District
Commander copies of Title 33-Navigation and
Navigable Waters, Chapter 1-Coast Guard, Department
of Homeland Seurity, Subchapter C-Aids to Navigation,
Part 67-Private Aids toNavigation, Outer Continental
Shelf and Waters Under the Jurisdiction of the United
States.

11. REMARKS

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