OWNERSHIP CHANGE FORM 5-14-21I.
1 I
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It:-:»i VS, DLI .e 1550 l`•il:ililgt`0: �, Or 20402
':.5' ,/, ?98Jt 39 I?98-705 i I PlHCgC`i.c�:n
Jim ionnucci, PE, CFW ounty zngf.lea-
STORMWATER.-A-UTHORUATION TO CONSTRUCT
OWP°IERSHIP CHANGE FORM
CURRENT ATC INI+ORxRe UO� v/� /
ATC Number: _15"1 _ 0 ( 1 R61
Project Name: L
Owner / Developer / Company Name:
Z'-txklA2U
Signing Official's Name and Title:
CC
(Title) Li
Mailing address:,,11 c z7 ;�,.- P.r city:
State: U�� — Zip Code: Phone: (Z$z) 0t4A 4 Pl Ir/ , `bec,V-3
NEW OWNER / DEVELOPER INFORMATION:
This request for change is a result of:
RECEIVED
❑ Change in ownership of company MAY 4 202 ❑ Name change for company
Change m ownership of property/facility
❑ Name change for property/facility ENGINEERING DEPARTMENT
❑ Other (please explain):
Owner /Developer fCompany Name: ( (- j �So(I
G, /o
Signing Official's Name and Titl-� C {c._
n(Person legally responsible for permit)
(Title)/
Mailing address: �. ✓O I �v� City: /
State: i t� Zip Code: zg�t5 Phone: (� l0) b 7�f ' 3Ol
EmW Albtm -' "1G't , attest ?:Iat this appi: at on fo::lact?/ew?ers1: - ^; gn 'raS EBBS.:eVfew'C an.0
:s accurate and complete to `=te beat of kncsled nderstand that if a,l r red arts of this a g`
y gi P pp!icaticn are not completed asd
?hat if all equired supporting ¢tforntat ett and attachments are not ncluded, this application package will be :etnned as incomple_e.
transfer ownership of ffie E.ut for zation to Ccnst-jct, and approved design. plans for the teferenoed dere!opmem, and transfer
responsibility for the consuction, and operation, and maintena ce a"'te stormwater control, and treatment faci! ties to }te new
owner. ^
Signature: (/�l/wl� �G
Date: 5�14 �Zort
a hlotary public for the County of state of
r AA-N Cr r nN\r"^ do hereby certify that 1'- W ,rx \\ C %L ft— personally appeared before
me this -12 day of 20 �, and acknowledge the due execution of the foregoing instrument.
Witness my hand and official seal.
%ttnntlitr/r ^ `
�J`.A SH04"'i40!
e cP Ffo: N Z
y a : My commission expires:
New Ownep��"2'�
�rrgrrtC�tt`��`�
1' E7W Ar, 44 attest that this application for a ownership change has been reviewed and is
accurate and complete to the best of my knowledge. I understand that if all required parts of this application are not completed and
that if all required supporting information and attachments are not included, this application package will be acceptable and will be
returned as incomplete. As the new owner, I accept full responsibility for the construction, and operation, and maintenance of the
stortnwater control, and treatment facilities in accordance with the Authorization to Construct, and approved design plans, and
applicable ordinances and rules of New Hanover County for the referenced development
Signature: �. �- ` V Date: 5- It 4 (ZOzI
L r f \ r a Notary Public for the County of I State of
NeAk-\ do hereby certify that t'.-v.1CY.yX y.- CSuJtL personally appeared before
methis i day of 20(_ J and acknowledge the due execution of the foregoing instrument.
Witness my hand and o&Icial seal.
`QQ�r Fto.,N
'OUBI�G :r2C
My commission xe pires: N,O"