NCC223772_FRO Submitted_20221108

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 Act before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Land
Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the appropriate
Regional Office. (Please type or print and, if the question is not applicable or the e-mail and/or fax information
unavailable, place NIA in the blank.)
Part A. t
1. Project Name SP 1�V .s�Y1 `Poj,r+- Seyey*A W es+ �S i A-C 2 A-C, 34 A-C, a.nd 5 R-G
2. Location of land -disturbing activity: County �A4W 41bV-ey_ City or Township VV 1 n1i10QiW�_
Highway/Street T Cd L&Yle- Latitude .31, V,095 Longitude T7.935
3. Approximate date land -disturbing activity will commence: 12l0 t 120Z Z _
4. Purpose of development (residential, commercial, industrial, institutional, etc.):_ ge5iAen:UcL�
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 0.95
6. Amount of fee enclosed: $ Nlia . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes_ x No Enclosed
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name R\4" �j ilt✓q E-mail Address rw_®'7bt e&kWi18eKs.c6M
Telephone q 10 - 541- Cr3 W- Cell # _ N A Fax # NIA
Landowner(s) of Record (attach accompanied page to list additional owners):
.Suear� we.� Builders, Inc'
.. q1-31.4- 44-4"I N1IA
Name Telephone Fax Number
120 pax l b I b 1-2_29NC6MA ("7 . SuiA-e_ C
Current Mailing Address Current Street A ress-
RO-Mnea NLc' �kctt.ot�L- C, ZB -
City State Zip City State Zip
10. Deed Book No. (o53 i Page No.__._-44 Z- Provide a copy of the most current deed.
Part B.
Company (ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) if the company or firm is a sole
proprietorship the name of the owner or manager may be listed as the financially responsible party.
W a& $u i U1 � cam
Ins ���C "1a wet � 1?u> �c�eYs .
Name E-mail Address
o U10 144
Current Mailing Address Current Street Ac2ress
City State Zip City State Zip

Telephone Fax Number
(a) if the Financially Responsible Party is not a resident of North Carolina, give name and street address of
the designated North Carolina Agent;
Name
Current Mailing Address
City State
Telepho
Email Address
Current Street Address
Zip City State Zip
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 dame. If the Financially Responsible Party
is ar�,Corporation, give name and street address of the Registered Agent:
lv
Name of Registered Agent E-mail Address
Current Mailing Address
City
Telephone
rrent Street Andress
State Zip City
Fax Number
State Zip
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 information should there be any change in the information provided herein_
4
Type or t name
O
Signatur
penis 1 cim 7i T
Title or Authority
bate
, a Notary Public of the County of ] Yis+on
State of North Carolina, hereby certify that C"Ycjj appeared
personally before me this day and being duly sworn ack�wledged that the above form was executed
by him.
Witness my hand �qqpotarial seal, this day of t�QVM �('� , 20 a�
4.
-Notary Public
4
Johnston _ Notary
� @a County
's MY Comm. Exp.
y, 02-01-2025 2P My commission expires