NCC231689_FRO Submitted_20230602

Goo N TY.,v0 APPLICATION FOR PERMIT FOR A File#
,.. ' y LAND DISTURBING ACTIVITY
o r- Under the conditions set forth by
0��
1 LD Fee Review Fee
!_ The New Hanover County
a Soil Erosion and Sedimentation Control Ordinance
Date Pd Date Pd
Z I•� •
'
f:NnitsH�lr'•
Engineering Department
Applicant or Applicant's Agent: CSD Engineering
Mailing Address: PO BOX 4041 Telephone Number: 910-791-4441 Fax Number: 910-791-1501
Wilmington NC 28406 Email Address: [e-mail]
Total Acres of Land Disturbance: 0.3 0 Purpose of Development: Building addition and parking lot expansion
Description of Land Disturbance: Land grading for parking lot and building pad
Address of Land Disturbance 4541 Technology Drive Latitude:34D18'35" Longitude: -77D52'26"
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: Black Forest Holdings, LLC Name: Black Forest Holdings, LLC
Address: 4541 Technology Drive Address: 4541 Technology Drive
City/State: Wilmington, NC City/State: Wilmington, NC
Zip Code: 28405 Zip Code: 28045
Telephone Number:_910-632-2383 Telephone Number: 910-632-2383
Email: [e-mail] FaxNumber Email:[e-mail] FaxNumber:
Location of deed(s)or instrument(s): County: New Hanover Book: 6307 Page: 1334
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: 3(21( 3 Name Gene McGonigle Title Manager
Signature I — ie.„------ C SIGN HERE
I, / + No tc o the/� unty of__il,„iltk_________er State of
North Carolina,hereby certify that (t'/1r(C OAJ '/t appeared personally before me this day and
f
being duly sworn acknowledged that the above form was exx tedd�byy z
Witn nd and n tary ,this / day of i (rf/c (� ,20 3 .
No M commission expires �/T � .
y p
DAVIE W. SMITH
NotVRIPblic, North Carolina
ew anover County
My Commission.Expires
May 08,2027
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 questi in connection related to this permit application.
Application Signature and Date
PLEASE COMPLETE ALL PORTIONS OF APPLICATION