NCC222973_FRO Submitted_20220819

APPLICATION FOR PERMIT FOR A File #
LAND DISTURBING ACTIVITY
Under the conditions set forth by LD Fee Review Fee
The New Hanover County
Soil Erosion and Sedimentation Control Ordinance
Date Pd Date Pd
Engineering Department
Applicant or Applicant's Agent: Three Guys Car Wash, LLC (Andrew Lazzaro )
Mailing Address: 5520 Oleander Dr.
Wilmington, NC 28403
Telephone Number: 910 - 8 3 3 - 74 3 9 Fax Number:
Email Address: Andy. lazzaronc@gmail . com
Total Acres of Land Disturbance: D. 9 Purpose of Development: Car Wash
Description of Land Disturbance: Disturbance for clearing/grading, parking, Building, Sidewalk Construction
Address of Land Disturbance 3819 Carolina Beach Rd.
Land owner(s) of record:
Name:
Three Guys Car Wash, LLC (Andrew Lazzaro
Address:5520 Oleander Dr.
City/State: Wilmington, NC
34010132.3"N Longitude:_77!52_1_27._44"M
STATEMENT OF FINANCIAL RESPONSIBILITY
Person or firm(s) financially responsible for the
land disturbing activity. If not a North Carolina
resident, you MUST have a N.C. agent. (List Below)
Name: Three Guvs Car Wash, LLC (Andrew Lazzaro
Address:5520 Oleander Dr.
City/State: Wilmington, NC
Zip Code: 28403 Zip Code: 28403
Telephone Number: 910 - 8 3 3- 7 4 3 9 Telephone Number:
910-833-7439
Email: Andy.lazzaroncogmail .comFaxNumber Email: Andy . lazzaronc@gmail . com
umber:
Location of deed(s) or instrument(s): County: New Hanover Book: 6525 Page: 2343
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 the information provided herein.
Date: I
Signature
Name Andrew Lazzaro
Title Member/Manager
I, ` t —aNotary Public of the County of INCW NGL03yCi State of
North Carolina, hereby certify that A n6t Vi W [_a.-z:Z6Cr 0 appeared personally before me this day and
being duly sworn acknowledged that the above form was executed by him.
Witness my and and notary seal, thi day of C b -C f , 20 ZI
Notary My commission expires
Permission to Enter on Land
I certify that I am authorized to grant and do
the land in question in connection related to thi
Appl
PLEASE COMPLETE ALL PORTIONS OF APPLICATION
m