NCC241070_FRO Submitted_20240410

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 and/
or fax information unavailable,place N/A in the blank.)
Part A.1. Project Name Donofrio Custom Home
Union Weddington
2. Location of land-disturbing activity: County City or Township
Highway/Street 2125 Garden "Latitude-80.725 Longitude 30.022
3. Approximate date land-disturbing activity will commence:4/1 5/24
4. Purpose of development(residential,commercial,industrial,institutional,etc.):Residential
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas):'25
6. Amount of fee enclosed: $ . The application fee of$100.00 per acre
(rounded up to the next acre)is assessed without a ceiling amount(Example:8.10 ac=$900.00).
7. Has an erosion and sediment control plan been filed? YesX No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Matthew Manger E-mail Address Mangerbuilders@gmail.
Telephone [phone] cell# Fax#
9. Landowner(s)of Record(attach accompanied page to list additional owners):
Gary and Deanna Donofrio 617-513-9575
Name Telephone Fax Number
14415 Blue Bay Circle
Current Mailing Address Current Street Address
Fort Myers, FL 33913
City State Zip City State Zip
10. Deed Book No. Page No. 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,
the name of the owner or manager may be listed as the financially responsible party.
Matthew Manger [e-mail]
Name E-mail Address
14406 Smith Rd
Current Mailing Address Current Street Address
Charlotte NC 28273
City State Zip City State Zip
Telephone [phone] Fax Number

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:
N/A
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
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.
Ar C � l Cc� l ice;t 1—
Type or,prin am Title or thority
326 zc{
Si n ure Date
-u5 , a Notary Public of the County of 1A•e. t-lthb(,,
State of North Carolina, hereby certify that la MQ,,,Q et— appeared
personally before me this day and being duly sworn acknowledged(that the above form was
executed by him. �/� l
Witness my hand and notarial seal, this ,( day of t" (Qrel� ,20 )`f
Seal
My commission expires pf r be)2-C
LORENZORAMOS
NOTARY PUBLNC
MECKIEN BURG COUNTY MO
COMMISSION b)(P.OCT.18,2026