NCC216128_FRO Submitted_20211105

APPLICATION FOR PERMIT FOR A File #
LAND DISTURBING ACTiVITI'
Under the conditions set forth by Lt7 t-ee Review Fee
The Neu, Hanover County
Soil ,Erosion and Sedimentation Control Ordinance
Date Pd Date Pd
Engineering Department
Applicant or Applicant's Agent:
Mailing Address: 631 0 Cha el Hill Rd. Telephone Number: Rq_-851- 422 Fax Number: 9J 9-8513968
Teich N.C,.27607 _ _ Email Address: R i B 11 BN
Total Acres of Land Disturbance: _. _1.15_ Purpose of Development: Apt./Retail
Description of Land Disturbance: Grclit fQ Z Buildings
Address of Land Disturbance 4649 F I i i D , Latitude: 34.161 p1.g, _Longitude:
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
resident, you MUST have a N.C. agent. (List Below)
Nance: _ 01 ind Forest, Associates, 1 1 C _ Name: Quail Forest Associates, LLC (a North Carolina Corporation*)
Address: 2600 Fairview Road Address: 2600 Fairview Road
City/State: R81e4ph. N.C_ _ City/State: Raleigh, North Carolina
Zip Code: 27608 Zip Code: 27608 * R, Neat Hunt, Registered Agent
Telephone Number: _ 10431-7986 � Telephone Number: 919-302-9700
Email: FaxNumber 1 - Ernail: [e-mail] FaxNunnber: [phone]
Location of deed(s) or instrument(s): County: New Hanover Book:. 4990 Page: 822
The above information is true and correct to the best of any 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:. J►11Y 16, RICh d Manager, uaiI Forest Associates, LLC
Title �` Q
Signature
L L(A l EM ks . baWj ...._ a Notary Public of the County of State of
North Carolina, hereby certify that RCekjKpA Col:bWappeared personally before me this day and
being duly sworn acknowledged that the above form was executed by him.
Witness nA hand and notary seal, this IV�_ day of __ J 24
Notary
b4if commission expires
SEAL Ashley B Goodell
NOTARY PUBLIC
New Hanover County, NC
1 certify that I am authorized to grant and do in fact grant pernnission to the Erosion Control Inspector and his agents to enter on
the land iniueslion in connection related to this permit application.
Application Signature and Date
PLEASE COMPLETE ALL PORTIONS OF APPLICATION