NCC230221_FRO Submitted_20230125

Check if this project is "04-funded ❑
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered b
activity under a common plan of development of this size as covered by the NCG01
and an acceptable erosion and sedimentation control plan have been completed ar kv Z62
Quality Section, N.C. Department of Environmental Quality. Submit the complete
Regional Office. (Please type or print and, if the question is not applicable or the e-ni...
number is unavailable, place NIA in the blank.)
Part A.
1. Project NameRoberson House
*if this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI).
2. Location of land -disturbing activity: CountyRutherford City or Township Logan Store
1441 Pea Ridge RD 35.391449-81.850039
Highway/Street LatltUde(decimal degrees) Longltude(deoimal degrees)
3. Approximate date land -disturbing activity will commence: as soon Is permit is issued
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Single Residence
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): approx. 1.5 acres
6. Amount of fee enclosed: $ oea0,00 . 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 J� Enclosed ElNo ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameJames L Roberson E-mail Addressjimmyrobe1 @bellsouth.net
Phone: Office # 828-429-0713 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
James Lee Roberson 828-429-0713 828-429-0713
Name Phone: Office # Mobile #
183 Creekside Dr Same
Current Mailing Address Current Street Address
Forest City NC 28043
City State Zip City State Zip
10. Deed Book No.2065 Page No. 4196 - 4198 Provide a copy of the most current deed.
CE10VED
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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 names) of the owner(s) may he fisted as the financially responsible party(ies).
James L Roberson
Company Name
183 Creekside Dr.
jimmyrobe1 @bellsouth.net
E-mail Address
Same
Current Mailing Address Current Street Address
Forest City NC 28043
City State
Phone: Office # 828-429-0713
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
Current Mailing Address
City
Phone: Office #
E-mail Address
Current Street Address
State Zip City
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(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:
Name of Registered Agent
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip
WE 1C ],EluVED
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Continued from Items 9 & 90 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:
Lauren Shows Roberson 828-429-0524 828-429-0524
Name Phone: Office # Mobile #
183 Creekside Dr. Same
Current Mailing Address Current Street Address
Forest City NC 28043
City State Zip City State Zip
Deed Book No. 2065 Page No.4196 - 4198 Provide a copy of the most current deed.
Landowner 3 of Record:
Name
Current Mailing Address
City
Deed Book No.
Landowner 4 of Record:
Phone: Office #
Current Street Address
State Zip City
Page No.
Mobile #
State Zip
Provide a copy of the most current deed.
Name Phone: Office #
Current Mailing Address Current Street Address
City State Zip City
Deed Book No. Page No.
Landowner 5 of Record:
Mobile #
State Zip
Provide a copy of the most current deed.
Name Phone: Office #
Current Mailing Address
City
Deed Book No.
Mobile #
Current Street Address
LOVED
State Zip City State Zip-_
ru21
Page No. Provide a copy of the, moost cyrrent.�ee l r r)

Continued from Item 9 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Lauren S Roberson jimmyrobe1 @bellsouth.net
Company 2 Name
E-mail Address
183 Creekside Dr
Same
Current Mailing Address
Current Street Address
Forest City NC 28043
City State Zip
City State Zip
Phone: Office # 828-429-0524
Mobile # [phone]
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
Phone: Office #
State Zip City
Mobile #
State Zip
IVED
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(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.
Lauren Shows Roberson
Type or print name
Signiftre
co-owner
Title or Authority
Date
1 r i
State of North Carolina, hereby certify that C61Lk4-e � 5 �5 abe.i'��aY1 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 da
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My commission expires ­6 - I ,:� - 1
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(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.
James Lee Roberson
Type or
ure
co-owner
name Title or Authority
'6t, /-// 0,3
_i _ V
Date
a Notary Public of the County of
State of North Carolina, hereby certify thaty�«Y"e 5 Le_e- IR,,6--.,f 50 n 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 J ` de
My commission expires it
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