NCC222882_FRO Submitted_20220811

Financial ResponsibilitylOwnership Form Sedimentation Pollution Control Ordinance
No person may initiate any land -disturbing activity on one or more acres as covered by the ordinance before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Rowan County
Environmental Management Department.
Part A
1. Project Name
Faith Charter School
2. Location of laud -disturbing activity (Highway/Street)
0. North Main St.
Latitude Longitude
° 35' 40 80° 27' 49"
F3�
3. Approximate date land -disturbing activity will be commenced
`07/21/2022
4. Purpose of development (residential, commercial, industrial, etc.)
Charter School
. Approximate acreage of land to be disturbed or uncovered
14
6. Person to contact should sediment control issues arise during land -disturbing
activity
Hubrich Contracting. INC
Attn: Steve Hubrich
Email Address
stave ,hubrichcontracting.com
Parcel ID Number
1412-300 / 412-013
�412-328
Cell Phone Number
[phone]

7. Landowner of Record
Faith Charter LLC
F_
Name
Current Mailing Address
a 4321 Medical Park Dr. Ste 100
Durham, NC 27704
8. Recorded in Deed Boot: Number
1401
L____ _ _
Part B
1. Person or Firm who are financially responsible for this
land -disturbing activity
Hubrich Contracting, INC.
Attn: Steve Hubrich
Name of Person(s) or Firm(s)
Current Mailing Address
4321 Medical Park Dr. Ste 100
Durham, NC 27704
Phone Number
[phone]
Landowner of Record
1
Name
Current Mailing Address
i
Page Number
385 and d 386 (two documents)
Person or Firm who are financially responsible for this
land -disturbing activity
Name of Person(s) or Firm(S)
Current Mailing Address
I
Phone Number
a. If the Financially Responsible Party is not a resident of North Carolina, give name and street address of a North Carolina
Agent.
Name of Agent
1
Current Mailing Address
i
i
Phone Number
Name of Agent
i
Current Mailing Address
I
Phone Number
i

b. If the Financially Responsible Party is a Partnership or other person engaging in business tinder an assumed name, attach
, give the name and street
a copy of the certificate of assumed name. If the Financially Responsible Party is a Corporation,
address of the Registered Agent.
Name of Registered Agent
Current Mailing Address
Telephone Number
L
Current ;Street
Telephone Number
The above information is true and correct to the best of my knowledge and belief and was provided by me tinder 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 authority to execute instruments for the Financially Responsible Person).
I agree to provide correctional information should there be any change in the information provided herein.
Name
i Steve Hubrich
Title or Authority
Signature Date
North Carolina,
1, Public of the County of State of Not
!Notary i
hereby certify that 'Oi-et-)e rr, appeared personally before e this day and being dul.worn acknowledgedday of
that the above form was executed by him/her. Witness my hand and seal of Notary, this
Notary
Seal
Checklist
Download a copy of the Erasion and Sedimentation
Control Plan -Checklist ED—B,
My commission expires
3-'315