HomeMy WebLinkAboutNCC216263_FRO Submitted_20211110FINANCIAL 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.
1. Project Name_ Troutman Enterprises Inc. Phase 2
2. Location of land -disturbing activity: County Cabarrus City or Township Concord
Highway/Street 1191 Central Drive NW Latitude 35,4402 Longitude-80.6146
3. Approximate date land -disturbing activity will commence: 9121
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.1
6. Amount of fee enclosed: $ 130.00 . 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 Troutman E-mail Address troutmanrentalQgmail.com
Telephone 704-782-3105 Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
T&T Custom Homes and Renovations, Inc. 704-782-3105
Name Telephone Fax Number
6310 Weddington Road NW
Current Mailing Address Current Street Address
Concord NC 28027
City State Zip City State Zip
10. Deed Book No. 14098 Page No. 115 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.
T&T Custom Homes and Renovations, Inc. troutmanrental@gmail.com
Name E-mail Address
6310 Weddington Road NW
Current Mailing Address Current Street Address
Concord NC 28027
City State Zip City State Zip
Telephone 704-782-3105 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
C ity
Telephone
E-mail Address
Current Street Address
State Zip City state Zip
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:
Blake Troutman
Name of Registered Agent
6310 Weddington Road NW
Current Mailing Address
Concord
City
Telephone 704-782-3105
NC 28027
State Zip
troutmanrental@gmail.com
E-mail Address
Current Street Address
City State Zip
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.
Blake Troutman
President
Type or print name Title or Authority
Signature Dale'
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I, Dod_%'g. l cxm:� or, a Notary Public of the County of _iC_alpar,-u, s
State of North Carolina, hereby certify that P-AC a, T",�uYrnwY, 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
Notary A')A IA HOR7p O �
My CO rssi arrus Cal, rCa,01j,,
orr E" 'res APr 71 2024
Aday of I%V, , 20 �2-
Notary
My commission expires (4,— `7 --woe ter`