HomeMy WebLinkAboutNCC233077_FRO Submitted_20231012 ri--cot, Pitt County
s a '4 Planning Department
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Development Services Building
4, 1717 W. 5th Street
C.0,0 Greenville, North Carolina 27834-1696 James F Rhodes,AICP
Telephone: (252)902-3250 Director
Fax: (252)830-2576
Financial Responsibility/Ownership Form
Soil Erosion and Sedimentation Control Ordinance
No person may initiate any land-disturbing activity on one or more contiguous acres as
covered by the Act before this form and an acceptable erosion and sedimentation control plan
have been completed and approved by the Pitt County Planning Department. (Please type or
print and, if question is not applicable,place N/A in the blank.)
Part A.
1. Project Name Scott Homesite
2. Location of land-disturbing activity: County Pitt
City or Township swift Creek , and Highway/Street
3. Approximate date land-disturbing activity will be commenced: 10/23/2023
4. Purpose of development (residential, commercial, industrial, etc.):
Clearing for residence
5. Approximate acreage of land to be disturbed or uncovered:2.23
6. Has an erosion and sedimentation control plan been filed? Yes X No
7. Person to contact should sedimentation control issues arise during land-disturbing activity:
Name Christopher and Helaina Scott Telephone 252-214-4491
8. Landowner(s) of Record (Use blank page to list additional owners):
Christopher and Helaina Scott
Name(s) Name(s)
5370 NC HWY 118
Current mailing address Street address
Grifton NC 28530
City State Zip City State Zip
9. Recorded in Deed Book No. MB 91 Page No. 36-37
Part B.
1. Person(s) or firm(s) who are financially responsible for this land-disturbing activity (Use
the blank page to list additional persons or firms):
Christopher Scott
Name of person(s)or Firm(s) Name(s)
5370 NC HWY 118
Current mailing address Street Address
Grifton NC 28530
City State Zip City State Zip
252-214-4491
Telephone Telephone
2. (a) If the Financially Responsible Party is a Corporation, give name and street address of
the Registered Agent.
Name(s)
Current mailing address Street Address
City State Zip City State Zip
Telephone Telephone
(b) If the Financially Responsible Party is a Partnership give the name and street address
of each General Partner(Use blank page to list additional partners):
Name(s) Name(s)
Current mailing address Current mailing address
City State Zip City State Zip
Telephone Telephone
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/her attorney-in-fact or if not an individual by an officer, director, partner, or
registered agent with 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.
Christopher Scott Owner
T • print name Title or Authority
10/3/2023
Signature Date
I, kit C.v)e. ((`'/ , a Notary Public of the County of ?' State
of North Carolina, hereby certify that C Lc k.5o Qqile `ECb-1-4
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 3 day of 0a4010er . 2033.
Li*A9ei --
Notary
My commission expires ld/o3/o)l/o?
NIC—OLE CHERRY
NOT RY Puauc
Pitt Countl-
M Noirt t h Carolin5.7
Y Commisson Expires 12/03/2025