20060508 Ver 2_More Info Received_20081016

Part 5: Deed Restrictions
By your signature in Part 7 of this application, you certify that all structural stormwater best
management practices required by this variance shall be located in recorded stormwater
easements, that the easements will run with the land, that the easements cannot be changed or
deleted without concurrence from the State, and that the easements will be recorded prior to the
sale of any lot.
See original variance application.
Part 6: Agent Authorization
If you wish to designate submittal authority to another individual or firm so that they may provide
information on your behalf, please complete this section:
Designated agent (individual or firm): 00) Ile S/ R,
Mailing address: P.O. Box 12828
City, State, Zip: Raleigh. NC 27605
Telephone: [phone]
Fax: [phone]
Email: [e-mail]
Part 7: Applicant's Certification
I, MARY (print or type name of person
listed in Part I, Item 2), certify that the information included on this permit application form is
correct, that the project will be constructed in conformance with the approved plans and that the
deed restrictions in accordance with Part 5 of this form will be recorded with all required permit
conditions.
Signature:
Date:
Title:
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Variance Request Form, page 6
Version 1: September 1998