NCC221366_FRO Submitted_20220407

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL. ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Soil Erosion and
Sedimentation Control Ordinance of the City of Greenville (Title 9, Chapter 8) before this form and an
acceptable erosion and sedimentation control plan have been completed and approved by the City of
Greenville, Engineering Division. (Please type or print and, if the question is not applicable or the e-mail
and/or tax information unavailable, place NIA in the blank.)
Part A.
1. Project Name Qf✓ G�nsidUGi�ror� l-1�'m� C�6�� wa
2. Location of land -disturbing activity: County
P-+-+
City or Township C ; �—Y� 06eenv . r'P
Highway/Street 06t K-501A 9 "D' /� Latitude S- 6 J 5 a] Longitude—77,1-I5<7gq
3. Approximate date land -disturbing activity will commence: A5A P A-Ac�
4 Purpose of development (residential, commercial, industrial, institutional, etc.): PC,5:aCrr- ' u
5 Total acreage disturbed or uncovered (including off -site borrow and waste areas) 0 S Ac ce 5
6. Amount of fee enclosed: $ . The application fee of $100.00 per acre (rounded
to the tenth of acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $900).
7 Has an erosion and sediment control plan been filed? Yes No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity -
Name /VhA06IYI lV1DIfO(
Telephone 7 " 9 I0
Jr Cell #
E-mail Address i } B ( U 3VA0' I.LN
1 �t31 3r4a l.coW+
Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
N AWA ICI MIAPIC260 oL 5,,?- - d,97- 30 10
Name Telephone
Fax Number
�O O � 6 NC v b6r) 06 4pQ OkS A✓eVtQ,91 +0 06 7V2
Current Mailing Address Current Street Address
O/VXPv, IVC. O-AP N 7117
City State Zip City State Zip
10 Deed Book No. � 3 t Page No. U J Provide a copy of the most current deed.
Part B.
Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehenswe list of all responsible parties on an attached sheet):
P�- n V� M G�r1 f-06 (_� (=- f s+e ' 13) (: c ri r-+
Name E-mail Address
Current Mailing Address Current Street Address
ChruC-,►�'�+`/ /✓C a�17 �r10Cc`J1.✓Ih+`1 �C o
City State Zip City State Zip
Telephone _� ,/97— 39 10 Fax Number

2_ (a) "the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) if the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Name of Registered Agent E-mail Address
Current Maifing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath (This form must be signed by the Financially Responsible Person if an individual
or his attorney -in -fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Person). I agree to provide
corrected j orrn� i n sh Id there by any change in the information providjed� herein.
e
Type or pri Title or Authority
Signature Date
1
1, ���- G1'—e_ a Notary Public of thCounty of Pi
State of North Carolina, hereby certify that _�rt�� �I��r
d appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this Leh day of b��� , 20
�,illll��ri
Notary
�4L �a�{
p G My commission expires
%`�•'�a. r • , Al .•
��111111��

213;22- a 3 7 pht eSearch Document Deta�Is
.+rt County, North Carolina Register of Deeds - Lisa P Nichols Guest User
Document Details
hoax jype Ut:;onpiion -- --
rat„ {Not Warrantedl 'Tate Filed Imagss
4231 1854 CONSOLIDATED REAL PROPERTY DEED 01/19/2022 813,32 AM 3
Pages
Address ��`Y - zir
CAPITAL TO COAST LAW GROUP
MISENHEIMER, TONY R
Pr-,.,s 1114prmatio ------
IRONWOOD CLUSTER FALKLAND TWP Lot_22
PH 1
IRONWOOD CLUSTER FALKLAND TWP LOL-23
PH 1
1140 KILDAIRE FARM ROAD SUITE 108 CARY NC 27511
GRANT[FS
MUNFORD, NATHAN L.
MUNFORD, MELISSA R.
0 2007 - 2022 Cott Systems, Inc.
Version 1.7-20.45
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