NCC231489_FRO Submitted_20230519

coo NTY.^, APPLICATION FOR PERMIT FOR A File#
4 , °4',,, LAND DISTURBING ACTIVITY
3''': A Under the conditions set forth by LD Fee Review Fee
ti0114, 0The New Hanover County
% ,. I al Soil Erosion and Sedimentation Control Ordinance Date Pd Date Pd
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Engineering Department
Applicant or Applicant's Agent: Scoot Holdings,LLC
Mailing Address: 8993 Unity Church Road,Denver,NC 28037 Telephone Number: 706-614-2299 Fax Number:
Email Address:[e-mail]
Total Acres of Land Disturbance: 0.67 Purpose of Development: Construct a new 664 SF drive-thru only coffee shop
Description of Land Disturbance: For the building,parking lot and drive-thru lanes
Address of Land Disturbance 6851 Market Street,Wilmington,NC 28405 Latitude: 34'15'41.79"N Longitude: 77°49'48.87"W
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)
Name: Nicholas H.Batuyios Name: Scoot Holdings,LLC
Address: 5 Cliff Cowl Address: 8993 Unity Church Road
City/State: Rocky Point,NY City/State: Denver,NC
Zip Code: 11778 Zip Code: 28037
Telephone Number: 631-833-1724 Telephone Number: 706-614-2299
Email: [e-mail] FaxNumber Email:[e-mail] FaxNumber:
Location of deed(s)or instrument(s): County: New Hanover Book: RB 6524 page: 1684-1690
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 informationn provided herein.
Date: `7 C \ Name �rl C..1,.=-�it-.. (—i : (? .`:Gt 4/ t Title
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�Stgnature 4,1 e/c c,.. /q'r J ‹,../tc,Illit ./
I, Embp.t' Cost—la IS________a Notary Public of the County of Rr(1P:0-US State of
0,44eA-emotina,hereby certify that appeared personally before me this day and
' d g el c u+sworn acknowledged that the a Eve form was executed b him.
Witness -h nd not h"s day of CY rC r) ,20 9 3 . `r
Not ,e f%r 4 (( L� - My commission expires �- 5- 05/v69 .
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Notary Public State of FrondeS "t' Ember EaSt 8ke
t iy ComnmsrOn_NH 029143
%q J Evan 081051224
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 in question in connection related to this permit application.
1 & 2( .H- &p:, 3/ /,p
Application Signature and Date
PLEASE COMPLETE ALL PORTIONS OF APPLICATION