NCC230042_FRO Submitted_20230106

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Jones Residence
2. Location of land -disturbing activity: County Burke City or Township Connelly Springs
2100 W. Paradise Harbor Dr. 35.7757 81.4875
Highway/Street LatltUde(decimaldegrees) LOngltUde(decimaldegrees)
3. Approximate date land -disturbing activity will commence: October 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.50 ac
6. Amount of fee enclosed: $200.00 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑ No ❑x
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity.
Name Justin Morrison E-mail [e-mail]
Phone: Office # Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Blair & Ann Jones
Name
131 Radium St.; Loft 3
Current Mailing Address
Marietta GA 30060
City State
10. Deed Book No. 2546
[phone]
Phone: Office # Mobile #
131 Radium St.; Loft 3
Current Street Address
Marietta GA 30060
Zip City
561
State
Zip
Page No. Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s) is
an individual(s). the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Blair & Ann Jones
Company Name
131 Radium St.; Loft 3
Current Mailing Address
Marietta GA 30060
City
Phone: Office #
State
blairjones [e-mail]
E-mail Address
131 Radium St., Loft 3
Current Street Address
Marietta GA 30060
Zip City State
Mobile # [phone]
Zip
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Daniel Shabeldeen [e-mail]
Name of Registered Agent E-mail Address
3145 Tate Blvd. SE 3145 Tate Blvd. SE
Current Mailing Address Current Street Address
Hickory NC 28602 Hickory NC 28602
City State Zip City State Zip
Phone: Office # 828.320.7252 Mobile # [phone]
Name of Individual to Contact (if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Type or print name,
Signa
Title or Authority
Date
a Notary Public of the County of C0?b
Gem
►c1
State of , hereby certify that ar CV)d At)r% JOr)12�5 appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this day of nbL--Y- 2021
DANILLA BUSTILL6
I
NOTARY PUBLIC
Cobb County
State of Georgia
My Comm. Expires March 28, 2023 My commission expires Nllnrc-h TV,2.023

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record
Name
Phone: Office #
Mobile #
Current Mailing
Address
Current Street Address
101-wYl e
e S 14 �00/cy
/�Q�i C '4
c Deli
City
State Zip
City State
Zip
`
�/
Deed Book
No.Page No.
Provide a copy of
the most current deed.
Landowner 3 of Record:
Name
Current Mailing Address
City
Deed Book No.
Landowner 4 of Record:
Name
Current Mailing Address
City
Deed Book No.
Landowner 5 of Record:
Name
Current Mailing Address
City
Deed Book No.
State Zip
Page No.
State Zip
Page No.
State Zip
Page No.
Phone: Office # Mobile #
Current Street Address
City
State Zip
Provide a copy of the most current deed.
Phone: Office # Mobile #
Current Street Address
City State Zip
Provide a copy of the most current deed.
Phone: Office # Mobile #
Current Street Address
City State Zip
Provide a copy of the most current deed.

Continued from Item 1 in Part 8 of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip
City
State
Zip
Phone: Office #
Mobile #
Company 3 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip
City
State
Zip
Phone: Office #
Mobile #
Company 4 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip
City
State
Zip
Phone: Office #
Mobile #
Company 5 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip
City
State
Zip
Phone: Office #
Mobile #