NCC220587_FRO Submitted_20220211

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 Environment and Natural Resources. (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 UNION CHURCH ROAD SUBDIVISION
2. Location of land -disturbing activity: County LINCOLN City or Township NA
Highway/Street UNION CHURCH RD Latitude 35d3lm55s N Longitude 8109m46s W
3. Approximate date land -disturbing activity will commence: 101112019
4. Purpose of development (residential, commercial, industrial, institutional, etc.): SINGLE FAMILY
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6-21 AC
6. Amount of fee enclosed: $ 455.00 . 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 NA E-mail Address
Telephone Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
SABITHA & JITEN SANGHVI AND PARATHAZATHEL, AND PARATHAZATHEL MOHANAN
Name Telephone Fax Number
320-1 PROSPERITY CHURCH ROAD, SUITE 256
Current Mailing Address Current Street Address
CHARLOTTE NC 28269
City State Zip City State Zip
10. Deed Book No. 2804 Page No. 315 Provide a copy of the most current deed.
Part B.
1- Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
SASITHA & ATEN SANGHVI AND PARATHAZATHEL AND PARATHAZATHEL MOHANAN MOHANPARAGYAH00.00M
Name E-mail Address
320-1 PROSPERITY CHURCH ROAD, SUITE 256
Current Mailing Address
CHARLOTTE NC 28269
City State
Current Street Address
Zip City
Telephone [phone] Fax Number NA
State Zip

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 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:
Name of Registered Agent
Current Mailing Address
E-mail 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.
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Signature Date
a Notary Public of the County of __
State of North Carolina, hereby certify that 5wk 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 / / ' day of 20—Lq_
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S PNA MONANAN
NOTARY PUBLIC
CAIARRUS COUNry
Notary
CAROLINA
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