NCC240640_FRO Submitted_20240306

/o�/o°NT Y' o APPLICATION FOR PERMIT FOR A
�" ��� LAND DISTURBING ACTIVITY File#
x -SA II 0 Under the conditions set forth by LD Fee Review Fee
'\ ''':r ::-, The New Hanover County
\z i ! Ali .a2
Soil Erosion and Sedimentation Control Ordinance
•'ST',ifSH6P 1�2� Date Pd Date Pd
Engineering Department
Applicant or Applicant's Agent:(ioG C\/p re5 l3t 1 Id,
Mailing Address: 75Qzo e dIe4t5N et Telephone Number:QlO al,2O'1 Fax Number:
W L)fll't +or- X C t! Email Address fiev'e Ce c.1Cvi htft6i .Coves
Total Acres of Land Disturbance: 1. D Purpose of Development: Sl r-V .carlt itl r'C td enC'(
Description of Land Disturbance:)L t 1.(A home-a`,t`Y'E 4',-its`; re:Si der-'e
Address of Land Disturbance 1 U J6,2 j J r c r' Viet Latitude:.-Me'Mo t i 3 F kht Longitude:Tr 5 i 3q l
-'eSer\rc\-Fibre du—y'- LQ+ Qb
STATEMENT OF FINANCIAL RESPONS I1il ILITY
Land owner(s)of record: Person or firtn(s)financially responsible for the
land disturbing activity. If not a North Carolina
t resident,you MUST have a N.C.agent. (List Below)
Name: C o yuw 3 t.,ten a A VA t t`(-eat II Name: Cove" Mo vgo,n h k.CAN1 \1
Address: \St$ .1v at\-TN -S E Address: 1S 1$ :LW 8:r A1n -Di Se-
City/State: ,e t\V i 0. , t.i.C- City/State: �o l;,vt c. , C
Zip Code: 2-t 422. Zip Code: 2 -2
Telephone Number:( or)3 V1-2.B%-1 Telephone Number: (a Cp o) 3 8"1 -2$B-1
Mot�ao.-F.+A.cv�et t 1 ►AOYo�u�•. F. , c I t Email: @ cJ o,,� t-cow FaxNumber Email: g.,„CA.;,\•cu."-, FaxNumber:
Location of deed(s)or instrument(s):County: eJPA.A., lea n,-ov e,y- 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: Zl i S'2 9- Name Mn v-gct.,✓1 V,may,-ei, t\ Title a pow
Signature /(,e7tM LC A\ -e.;�,e4
I, 11 4,\r\ t'°kr-►: a Notary Public of the County of e.Ti -i,r ( `;,.r,;_ .4. State of
North Carolina,hereby certify that \c,Ysc_i-e-N IA L t'ke-,\\ appeared personally before me this day and
being duly sworn acknowledged that the above folio was executed by him,
Witness my hand and notar seal,this 1�� day of j- ,,.•ti,r ,� ,20 ---
Notary My commission expires '•y//;s0. 1.0�`7
SEAL KAROLYN HARRIS
Notary Public,North Carolina
New Hanover County
My Commission Expires
Permission to Enter on Land 03I05t2028
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.
Application Signature and Date
PLEASE C'I MPLETE ALL PORTIONS OF APPLICATION