NCC223540_FRO Submitted_20221012

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: TIM CLARK - MCKIM AND CREED INC
Mailing Address: 243 NORTH FRONT STREET Telephone Number: 910.343.1048 Fax Number: 910,251,8282
WILMINGTON NC 28409
Total Acres of Land Disturbance:
Description of Land Disturba
Address of Land Disturbance
Email Address: [e-mail]
3.94 AC Purpose of Development: RESIDENTIAL - SENIOR LIVING
GENERALLY THE LIMITS OF THE BUILDING, PARKING AND STORMWATER POND
Road and 217 MiddleSoundLatitude: 34"16'12.92"N Longitude: 77°48'56.13"W
Land owner(s) of record:
Name: BRAD Residence at Canopy Pointe, LLC
Address: 1630 Military Cutoff Road, Suite 104
City/State: Wilmington, NC
Zip Code: 28403
Telephone Number:
910,338,3349
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: BRAD Residence at Canopy Pointe, LLC
Address: 1630 Milita Cutoff Road, Suite 104
City/State: Wilmington, NC
Zip Code: 28403
Telephone Number: 910,338.3349
Email:chria.e@6lueddgealian1ic,00m FaxNumber NIA Email: [e-mail] FaxNumber: N/A
Location of deed(s) or instrument(s): County: NEW HANOVER COUNTY Book: Page:
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: 20 2. Z_ Name Christopher L. Eisenzimmer
Signature
Title MANAGER
I, UaAlD 111 tW_ ` . '(DIW o1V_aLK ----/ a Notary Public of the County of i� bbMn 0 kfAC State of
North Carolina, hereby certify that (,�1 hjt9V L appeared personally before me this day and
being duly sworn ac owledged that the above form was executed by him.
Witness han a e , this � day of f- , 20 12
Notary My commission expires
SEAL CAROLINE P, EDWARDS
` Notary Public, North Carolina
�� New Hanover County
My Commission Expires
44•...•� � April 06, 2027
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 *question in can
is permit application.
G//z -;,-
Application Signals d Date 1'��
I.E ''v COMPLETE ALL PORTIONS OF APPLICATION