NCC242770_FRO Submitted_20240909

--6v_ctrv.:�., APPLICATION FOR PERMIT FOR A
,-(;4 ° R File#
�> / ati `.� , LAND DISTURBING ACTIVITY
r / `A ., \ Under the conditions set forth by LD Fee Review Fee
C� IIi.%r; „1
� The New Hanover County
' A! tit i�'4,,,f Soil Erosion and Sedimentation Control Ordinance
Date Pd Date Pd
Engineering Department
Applicant or Applicant's Agent: 8055 Masonboro LLC
Mailing Address: 6316 Marywood Drive Telephone Number: Fax Number:
Wilmington, NC 28409 Email Address:
Total Acres of Land Disturbance:. Z•4 Z.-Purpose of Development: Residential
Description of Land Disturbance: Clearing and grubbing, paving, grading and utilities
Address of Land Disturbance 8055 Masonboro Sound Road Latitude:34.1638 Longitude:'77.8558
STATEMENT OF FINANCIAL RESPONSIBILITY
Land owner(s)of record: Person or firm(s)financially responsible for the
land disturbing activity. If not a North Carolina
8055 Masonboro LLC resident,you MUST have a N.C.agent.(List Below)
Name: Name: 8055 Masonboro LLC
Address: 6316 Marywood Drive Address: 6316 Marywood Drive
City/State: Wilmington, NC City/State: Wilmington, NC
Zip Code: 28409 Zip Code: 28409
Telephone Number: 910-279-3365 Telephone Number: 910-279-3365
Email: [e-mail] FaxNumber Email:[e-mail] FaxNumber:
Location of deed(s)or instrument(s): County: New Hanover County Book: 6519 Page: 2798
The above information is true and correct to the best of my knowledge and belief and was provided by me while under oath.
(This form must be signed by the financially responsible person if an individual and by an officer, director,partner, attorney-in-
fact, or other person of authority to execute instruments for the financially responsible person if not an individual.) I agree to
provide corrected information should there be any change in �r0i.the_ ma�information// provided herein. //
Date: 20 _3 Name fl/r eZ f'� 4' Title A S, /lL
Signature
I, i d:l.,Vl i ccx. Ka_jr 2(►'x0tfin a Notary Public of the County of ]ve,Li 1— .','e_r State of
North Carolina,hereby certify that Per n, e-c-bib ie_f't fSC1,_ appeared personally before me this day and
being duly sworn acknowledged that the above form was,executed by him.
Witness my han and notary seal ' S' day of ! ,4A,An be r ,20 Z-S .
Notary ° ..._ Art 'on expires {Y10.4:s at , c02oc, r?
i NOTARY PUBLIC
SEAL New Hanover County
North Carolina
My Commission Expires QI G
Permission to Enter on Land
I certify that I am authorized to grant and do in fact grant permission to the Erosion Control Inspector and his agents to enter on
the land in question in connection related to this permit application.
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Application Signature and Date
PLEASE COMPLETE ALL PORTIONS OF APPLICATION