NCC230388_FRO Submitted (2)_20230213

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 Once. (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. Governors Club - Lot 872 Owen
1. Project Name
or Townshi Williams
2. Location of land -disturbing activity: CountyChatham c; tY P
Highway/Street 57809 Owen Latitude 35.8514 Longitude-79.0495
3. Approximate date land -disturbing activity will commence: 02/21 /2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 0.37
6. Amount of fee enclosed: $ 65.00 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
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name E-mail Skela E-mail [e-mail]
Telephone cell # 919.537.1491 Fax # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Gent and Anila Hito 919.656.3242 N/A
Name Telephone Fax Number
480 Sun Forest Way 480 Sun Forest Way
Current Mailing Address Current Street Address
Chapel Hill NC 27517 Chapel Hill NC 27517
city State Zip City State Zip
10. Deed Book No. 2327 Page No. 0064 Provide a copy of the most current deed.
Part B.
1. 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,
Me name of the owner or manager may be listed as the (nancially responsible party.
Gent Hito [e-mail]
Name
480 Sun Forest Way
Current Mailing Address
Chapel Hill NC 27517
City State Zip
Telephone [phone]
E-mail Address
480 Sun Forest Way
Current Street Address
Chapel Hill NC 27517
City State Zip
Fax Number N/A
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2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
5TA E-mail Address
Current Mailing Address Current Street Address
City
Telephone
State 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 Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Name of Registered Agent
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
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.
Gent Hito Owner
Typo or print name
Si
Title or Authority
2/8/2023
Date
a Notary Public of the County of
State of North Carolina, hereby certify that Gl� I—) 140 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 day of ., _ 20
ANDREW J O'CONNELL III
Notary Public - North Carolina otary
�County
MY Cammiss1001 Vires Oct 30, 2027
My commission expires 1b 3�
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