NCC231829_FRO Submitted_20230613

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 Soil Erosion and
Sedimentation Control Ordinance of the City of Greenville(Title 9, Chapter 8)before this form and an acceptable
erosion and sedimentation control plan have been completed and approved by the City of Greenville,
Engineering Department. (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 /Y� (odS7Q ? ?7 v/ �0,�- 2iq 4" Suot/2/.L
2. Location of land-disturbing activity: County d— City or Township '"/�edr]dl/%�
Highway/Street 4,20 L -s.9-,-. Latitude(decimal degrees) Longitude(decirnal degrees)
3. Approximate date land-disturbing activity will commence: o!o/ 20 3
4. Purpose of development (residential, commercial, industrial, institutional,// etc.): _es./.44:1 44z-/
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): - 51-9'
6. Amount of fee enclosed: $ /190•DD . The application fee of$100.00 per acre or portion
thereof (rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre
application fee is $900).
7. Has an erosion and sediment control plan been filed? Yes lg Enclosed ❑ No ❑
8. Person to contact, should erosion and sediment control issues arise during land-disturbing activity:
Name je)14% 1-5- Z /d - -c— E-mail Address .t/eio.,Jzze9
Phone: Office # Mobile# 2— '7/2- Z )40
9. Landowner(s)of Record (attach accompanied page to list additional owners):
S/�fG7 Z/i-a - 2sz-3c4 7- A
Name Phone: Office# Mobile#
427 Ze C -• /07Z• /9s�
Current ailing Address Current Street Address
41:/2l/i//e- Z ,e)
City State Zip City State Zip
10. Deed Book No. 0O5/54O Page No.l7O 54oO 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).
\D Sol).-2-1 SU `L c-btfv1
'.•mpany Name E-mail Address
LEGACY CC. 11-ri 11 Li-
Curre Mailing Address Current Street Address
1t \J 2t50
City S to Zip City State Zip
Phone: Office Mobile#
Note: If the Financially Re onsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and @ted 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 Responsib - Party is a domestic company registered on the NC Secretary of State
business registry, give name an. street address of the Registered Agent:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip C State Zip
Phone: Office# Mobile
Name of Individual to Contact (if Registered Agent is a corn pan•
(b) If the Financially Responsible Party is not a resident of North C. olina, give name and street address
of the designated North Carolina agent who is registered on the NC cretary of State business registry:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City Stat- Zip
Phone: Office# Mobile#
Name of Individual to Contact(if Registered Agent is a company)

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:CA(ri if/ 4 , J/
upzhvQ
Name / Phone: Office# Mobile#
Z 1-, ..1c 61. Arpz /9V 6,i- -8---
Current M iling Address Current Street Address
()/A 1 r,e-(/,// 7; zee)
City / State Zip City State Zip
Deed Book No. £ 0 5.409 Page No. a0 v Provide a copy of the most current deed.
Landowner 3 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 4 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.

Continued from Item I 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.
►ompany 2 Name E-mail Address
Curren k ailing 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 ddress
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#

(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.
mp nyDBANa
They infor n 's tr e an e best of my knowledge and belief and was provided
y e under o th. (This for must be signed by the Financially Responsible Person if an individual(s)
or his attorney-. , 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.
0-0 -)- AD2l074 O2VER
y e or print Title or Authority
Si ature Date
1, t\U U k Ry , a Notary Public of the County of IONA l=tsr;n
Sta - of North Carolina, hereby certify that aV\116, u-b\1 S lAdI 1Atk 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 (y\oM , 20
J. BROOKE NYE
ota
k\)\14-
- ,Notary Public 1 /�
Davidson Co.,North Carolina M'ommission expires 121 �1 I I
My Commission Expires Dec.13,2027