NCC241507_FRO Submitted_20240517

RE:Application for Permit for a Land Disturbing Activity
Address of Land Disturbance: 3742 Pergola Terrace
Land Owner of Record: Daniel E. Koeller and wife, Mary Joseph Koeller
As the property owner of Record of 3742 Pergola Terrace(also known as Lot 19 Airlie at Wrightsville
Sound), I allow Grace Custom Homes, LLC(General Contractor)to work on my property for the land
preparation and construction of a single-family residence. Grace Custom Homes, LLC Is financially
responsible for the work performed.
Date ' a.,
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Signature
I, jtA.Y7 a Notary Public of the County of
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State of North Carolina, hereby certify that Leo lc, t. O et A
appeared before me this day and being duly sworn acknowledge that the above form was executed by
them.
Witness my hand and notary seal, this day of 4P4L , 200234
Notary < My Commission Expires 4 .:2- t
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