NCC216226_FRO Submitted_20211109

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007
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. John Smith Road Subdivision - Phase 1 - Single family
1. Project Name
2. Location of land -disturbing activity: County Rutherford City or Township Rutherfordton
Highway/StreetJohn Smith Rd Latitude 35.3438 Longitude -81.9661
3. Approximate date land -disturbing activity will commence: ASAP
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 8.80
6. Amount of fee enclosed: $ 2000.00 l 5a5.00 The Express Permitting application fee is a dual charge.
The normal fee of $65.00 per acre is assessed without a ceiling amount. In addition, the Express
Permitting supplement is $250.00 per acre up to eight acres, after which the Express Permitting
supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585). NOTE: Both fees are
rounded up to the next whole acre and need to be paid by separate checks to NCDENR.
i . ' I las .., . e--s 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 David Odom E-mail Address [e-mail]
Telephone [phone] cell # 828-289-4355 Fax # n/a
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Gateway Housing LLC
Name Telephone Fax Number
135 S Main St Same
Current Mailing Address Current Street Address
Marion, NC 28752
City State Zip City State Zip
10. Deed Book No. 2040 Page No. 2565-2568 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.
Gateway Housing LLC [e-mail]
Name
135 S Main St
Current Mailing Address
Marion, NC 28752
city
State Zip
Telephone [phone]
E-mail Address
Same
Current Street Address
City State Zip
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:
Name
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City
Fax Number
State Zip
(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:
Angela Anderson [e-mail]
Name of Registered Agent E-mail Address
135 S Main St Same
Current Mailing Address Current Street Address
Marion, NC 28752
City State Zip City State Zip
Telephone [phone] Fax Number
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Odom Engineering, PLLC [e-mail]
Engineering Firm or other consultant E-mail Address
Pete Dickerson 828-247-4495 ext. 11 n/a
Individual contact person (type or print) 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.
Angela Anderson Vice President
TCnt pme Title or Authority
W29/2021
Signature Date
I, a Notary Public of the County of I V PP
State of North arolina, hereby certify that 11G, An�/kV66 I appeared personally
before me this day and being duly sworn acknowled ed that the above form was executed by him.
Witness my hand and notarial seal, this O- q day of i£m bf r , 20 ,9 1
Notall
Seal
BRITTANY R BLALOCK
Notary Public - North Carolina
Mc Dowell County
My Commission Expires May 14, 20124
My commission expires ,/1�c5lL)--�LLI