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

U.S. DEPARTMENT OF HOMELAND SECURITY U.S. Coast Guard APPLICATION FOR CLASS I PRIVATE AIDS TO NAVIGATION ON ARTIFICIAL ISLANDS AND FIXED STRUCTURES (Please read instructions on page 2)										OMB Approved: 1625-0011 Expiration Date: December 31, 2017
1. NAME AND ADDRESS OF CORPORATION OR PERSON MAKING APPLICATION						2. ACTION REQUESTED FOR PRIVATE AIDS TON AVIGATION A.  ESTABLISH AND MAINTAIN B.  CHANGE OWNERSHIP C.  CHANGE EQUIPMENT D.  MOVE E.  DISCONTINUE F. DATE OF ACTION _________________
3. POSITION
A. GENERAL LOCALITY AND GRID AREA						B. LATITUDE					C. LONGITUDE
D. BLOCK NUMBER	E. SIGN					F. LEASE NUMBER					G. WELL NUMBER
4. LIGHT
A. CHARACTERISTICS FLASH ______ SECONDS	COLOR: WHITE  RED  ECLIPSE ______ SECONDS			B. NUMBER INSTALLED							C. ILLUMINANT(Check)  ELECTRICITY  OTHER (Specify) ________
D. HEIGHT ABOVE MEAN HIGH WATER	E. VOLTS		F. AMPERES				G. INSIDE DIAMETER				H. CANDELA (If known)
							LENS	GLOBE
5. SOUND SIGNAL (Characteristic will be one two-second blast every twenty seconds)
A. CLASS  A (2-Mile)  B (1/2-Mile)	B. MANUFACTURED BY										C. MODEL NUMBER
6. STRUCTURE
A. COLOR		B. HEIGHT ABOVE MEAN HIGH WATER							C. DEPTH OF WATER BELOW MEAN LOW WATER
7. AUTHORIZED BY U.S. ARMY CORPS OF ENGINEERS PERMIT NO.
8. PERSON IN DIRECT CHARGE OF THE OPERATION AND MAINTENANCE OF THE PRIVATE AID TO NAVIGATION
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 private aid(s) to navigation. Attached to this application are:
A.  LOCATION PLAT		B.  PRINT OF STRUCTURE							C.  AIDS TO NAVIGATION EQUIPMENT LIST
D.  CERTIFICATE REQUIRED BY 33 CFR 67.10-1 (4)
DATE						SIGNATURE
						TITLE
FOR U.S. COAST GUARD USE
10. FROM: Commander U.S. Coast Guard District
THE ACTION DESCRIBED ABOVE IS  APPROVED  APPROVED SUBJECT TO THE COMMENTS IN BLOCK 11 ON REVERSE					NOTICE TO MARINERS  WILL BE ISSUED  WILL NOT BE ISSUED
C. CHARTS AFFECTED					D. NAME OF AID(S) TO NAVIGATION
E. DATE	F. SIGNATURE (By direction in accordance with 33 CFR 67)

INSTRUCTIONS
The applicant will complete items 1 through 9. Submit the completed form, via postal mail, electronic mail, or facsimile to the Commander of the Coast Guard District in which the aids will be located. 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 sound signal, the certificate required by 33 CFR 67.10-1 (4).	You may obtain copies of Title 33, Code of Federal Regulations, Navigation and Navigable Waters, Chapter 1 - Coast Guard, Department of Homeland Security, Subchapter C - Aids to Navigation, Part 67 - Aids to Navigation on Artificial Islands and Fixed Structures from the Coast Guard District Commander in which the aids will be located.
11. REMARKS
Privacy Notice AUTHORITY: 14 U.S.C. 83. PURPOSE: To obtain approval to establish a private aid to navigation on an artificial island or fixed structure, the applicant must submit CG 4143 (Application for Class 1 Private Aids to Navigation on Artificial Islands and Fixed Structures). Information about the private aid to navigation (type, color, geographic position), as well as the applicant’s contact information is stored in the U.S. Coast Guard’s United States Aids to Navigation Information Management System (USAIMS). USAIMS is the U.S. Coast Guard’s comprehensive database for managing information about aids to navigation. USAIMS has user access controls in place to govern who may view or access information. ROUTINE USES: Authorized U.S. Coast Guard personnel will utilize this information to contact owners in the event of a discrepancy or a mishap to a private aid to navigation. Any external disclosures of data within this record will be made in accordance with DHS/ALL-002, Department of Homeland Security (DHS) Mailing and Other Lists System, November 25, 2008, 73 FR 71659. CONSEQUENCES OF FAILURE TO PROVIDE INFORMATION: Mandatory. Failure to provide the required contact information will prevent approval to establish a Class I Private Aid to Navigation on Artificial Islands and Fixed Structures.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The U.S. Coast Guard estimates the average burden for this report is 1 hour. You may submit any comments concerning the accuracy of this burden estimate or any suggestions for reducing the burden to: COMMANDANT (CG-NAV-1), U.S. COAST GUARD STOP 7418, 2703 MARTIN LUTHER KING JR AVE SE, WASHINGTON DC 20593-7418 or OFFICE OF MANAGEMENT AND BUDGET, PAPERWORK REDUCTION PROJECT (1625-0011), WASHINGTON, DC 20590-0001.

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