NCC230237_FRO Submitted_20230126

APPUICATION FOR PERM[T FOR A
LAND DISTURBING ACTIVITY
Under the conditions set fortis by LD Fix Review Pee
The New Hanover County
Sati Erosion and Seditneu a im Control Ordinance
Dare Pd' Hate y+a
Englaftwing Department
Alqdkmt or Applicant's Agent: , 4 li ITV I S CU r4 St I-L4 G; ; U't
Mailing Address' (t)o(- 5�A,In m LTI G �t C A 11s C � Telephone Number:(,1a1. (,S°r�psuc Nmnbex:
1l� ,1nt;NG N Q.Q. IZ Email Addresr Q� rkgKr><d.A2\S kJ C0►41
Total Acres of Land DistuxtMMM . 5 1'MPM ofDevel®pment:?,,'1c� s; Vsl� QV,,,, howt --
Description of Land Disturbance: 1�•,,1 D g w•e-- ) RRI wE mN:; w 1, it'd izc Wk_-at 4A. ,
Address of Land Disturbance 1224 -r1uaLvaall�- v. Latitude: i s /5r.(eI.ongiWde:-17'S3� rz (+s"
�nt�C.un,►,aq�o� 1.tC. �s4eq
STATEMENT OF FINANCIAL REVONSISILITY
Land ewtrer(s) of rteoad: Person or M=(s) fginanefally responsibile for the
1F51,► ((0 � a H hwdad�isttsrbinggac iivity. If not a N Carolina
..
you ; have a NX- (1 I$dow)
Name- 7 vc3 6 li-T %. �A f i ry E Name: /` U 'bKv t S r-a
Address: I LI T iZ�To ra C, �- _ Address: 1006
City/state: \h! i %g i N 41 L— City/State: V11j nor 1 hJg j 1,4 N C
Zip Code: 33t4 Nc, Zip Code:
Telephone Number. "l t °t - 6 a3 `qc o :2 Telephone Numbest . Q tb - U a L < 2j; (-a- - - - --
Email: r o -P CPaxNnrnber 'l: qri a s Ea . Cu N FaxNumber.
Location of deeds) or tnslrument(s): County: ]Book: i 3 Page: 6 1-7
The above information is true and cmTect to the best of my knowledge and lied and wilts provided by me while under oath.
(This form must be signed by *0 financially responsible person if an individual and by an officer, director, partner, attorney -in -
fact, or other person of and mr y to execute instruments for the financially responsible persons if not an individual.) I agree to
provide corrected ' 'ors should dmzc be any change in the informatiou provided herein.
7 IDaw: I-L zz- 2 Z, Name � �ul/ �� � is Title j�c�,icri _ -
Signasure
1 C
North C.aiolina,
a Notary Nbhc of the County of
State Of
catify that appeared perst wally before me this day and
being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notary this ? � day of
Nay - --_ my commission expires G (i a ! L If
g viraj Parikh
Notary pubic
New Hanover County, NC
1p==kd n to er one My Commission Expires 412412024
1 c eltify that I am authorized to grant and do in fact grant permission to the Erosion Control Inspector and his agents to enter on
the lamb in questi qQ in connection related to this permit awlicatio,- 0 1
Application Signature and Date
PLEAfSR +COMPILR M ALL PORTIONS OF APPLICATION