NCC243590_FRO Submitted_20241120

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N!?•4.0 APPLICATION FOR PERMIT FOR A
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�y LAND DISTURBING ACTIVITY
Under the conditions set forth by
/\�, o LD Fee Review Fee
The New Hanover County
` ai� Soil Erosion and Sedimentation Control Ordinance
Date Pd Date Pd
LISHED
Engineering Department
Applicant or Applicant's Agent: Figure Eight Island Yacht Club, Inc. (Peter Gushanas)
Mailing Address: 15 Bridge Rd. Telephone Number: 910-686-0631 Fax Number:
Wilmington, NC 28411 Email Address: [e-mail]
Total Acres of Land Disturbance: __Purpose of Development: Commercial
Description of Land Disturbance: Grading and construction of parking area, and storrnwater facilities.
Address of Land Disturbance 15 Bridge Rd. Latitude:34DEG 16'22.00"N Longitude:'77DEG 45'16.86`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: Figure Eight Island Yacht Club, Inc. Name: Figure Eight Island Yacht Club,Inc.
Address: 15 Bridge Rd. _ __ Address: 15 Bridge Rd.
•City/State: Wilmington, NC City/State: Wilmington, NC
Zip Code: 28411 _ Zip Code: 28411
Telephone Number: 910-686-0631 Telephone Number: 910-686-0631
Email: [e-mail] FaxNumber Email:[e-mail]
FaxNumber:
Location of deed(s) or instrument(s): County: New Hanover Book: 1231 Page: 0735
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: *CI /17 i Name Peter Gushanas Title General Manager/COO
I, Cl-9-4 _ _. ()t1+.Ar-cA_i r.:A aa�Notary Public of the County of AW.� V k Cyr ov-v✓ State of
North Carolina, hereby certify that•-l"" /Y G v SY - c..-S appeared personally before me this day and
being duly sworn acknowledged that the above form was executed by him.
Witness my an no d I -:1 t t is 1'7 day of V c*Ob.-✓ ,20
Notary \ ,• f1�li/O; My commission expires OC..4- 1 / 7 07 (o
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Permission to Enter' ,.•
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I certify that I am authordd +went and do in fact grant permission to the Erosion Control Inspector and his agents to enter on
the Ian in q stion in connection related to this permit application.
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PLEASE COMPLETE ALL PORTIONS OF APPLICATION