NCC210997_MODIFICATION Supporting Documents_20210628

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 NIA in the blank.)
Part A. Murphy's Farm Apartments
1. Project Name
2. Location of land -disturbing activity: County Burke City or Township Morganton
Highway/Street East College ❑r. Latitude 35043'25.53"N Longitude 81 °40'28.96"W
3. Approximate date land -disturbing activity will commence: 5/01 /2020
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 19.65 Acres
6. Amount of fee enclosed: $ 65 ($1235 Previously Paid) 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 No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Blake Muldrow E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
CCHU Morganton, LLC
Name Telephone
219-A E. Washington Street
Current Mailing Address Current Street Address
Greenville SC 29601
City State
10. Deed Book No. 2530
Zip City
Page No. 441
Fax Number
State
Zip
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.
Homes Urban, LLC blake.muidrowghomesurban.com
Name
219-A E. Washington Street
Current Mailing Address
Greenville Sc 29601
E-mail Address
Current Street Address
City State Zip City State Zip
Telephone [phone] Fax Number

t

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:
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:
CCI;IJ Morganton, LLC russ.davisCahomesurban.com
Name of Registered Agent E-mail Address
219-A E. Washington Street
Current Mailing Address Current Street Address
Greenville SC 29601
City State Zip City State Zip
Telephone [phone] Fax dumber
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.
J. Russ Davis, Key Principal
Type o ntVie Title or Authority
XV64
April 26, 2021
igna re Date
I, n� � �LO'c�7x�%t , a Notary Public of the County of OeoAjElf-
froi's,' �/bRUar�,a1l�-
State of41-rt#GaFe4ma, hereby ce ify that T gos s ?k01 S UA 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 t day of �'t�.�1€ 20 A
Notary
Seal
My commission expires
EDWARD J MONDOR Ill
Notary ftmw wo of Borth CN Wi U
MY COMM160161Expirss
September 05,229

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