NCC220956_FRO Submitted_20220309

COB Pitt County
Planning Department
' Development Services Building
Ham, 1717 K 5" Stredt
" 0 Greenville, North Carolina 27834-1696
Telephone: [phone] James F. Rhodos, AlOP
Fax: [phone] Director
Financial Responsibility 1 Ownership Form
Soil Erosion and Sedimentation Control Ordinance
Na person may initiate any land -disturbing activity on one or more contiguous acres as
coveted by the Aot before this form and an acceptable erosion and sedimentation control plan
leave been completed and approved by the Pitt County Planning Department. (PIease type nr
print and, if question is not applicable, place N/A in the blank.)
Part A.
1, Project Natne� 1 ..i...(, r; } . L /-tea 1 i �.�C y
2. Location of land -disturbing activity: County�lu'' T
City or Township _G_ at(', —t> , and Highway/strect Lq W'y 7"
3. Approximate date land -disturbing activity will be commenced:
4. Purpose of development (residential, commercial, industrial, etc.):
P ! C, t (al iY- (' i 1. AI -
5. Approximate acreage of land to be disturbed or uncovered:.=
6. Has an erosion and sedimentation control plan been fled? Yes ./'� No
7.
8.
Person to contact should sedimentation control issues arise during land - disturb ing_activity:
Name J+jQ-j0,Y 11J�' ? _ Telephone
Landowner(s)lofRecord (Use blank page to list additional owners):
1�) "mot i
a€ne(s) Names)
Current maliling address Street address
Crty State Zip City State
Zip
9. Recorded in Deed Book No. 1'y Page No._�
Part B.
1. Person(s) or firm(s) who are financially responsible for this land -disturbing activity (Use
the blank pa�e to list additional persons or firms):
/Anne of person s) or, Finn(s) Name(s)
Current mailing address Street Address
City State Zip City state Zip
Telephone Telephone

2. (a) If the Financially Responsible fatty is a Corporation, give name and street address of
the Registered Agent,
Nante(sl
6rrent mailing address Street Address
' `j t U& t!C
Ci ate .Zip City state Zip
Telephone Telephone
(b) If the Financially Responsible Party is a Partnership give the name and street address
of each General Partner (Use blank page to list additional partners):
Nantes) Names)
Currant trailing address Current ntalling address
City state Zip City State Zip
Telephone Telephone
The above information is true and correct to the best of my knowledge and belief and was
provided by one under oath. (This form roust be signed by the financially responsible person if
an individual or his/her attorney -in -fact or if not an individual by an officer, director, partner, or
registered agent with 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. 1 `�
'S
Ty a or )I. t name Title or At Kority
i 2, - $ 2'
Signature Date
a Notary Public of the County of _ 6 _ State
of North Carolina, hereby certify that 0-r-b" �Y
appeared personally before me this day and being duly sworn actwowledged that the above form
was executed by him,
Wittress my hand and Notarial seal this"tlt day of
F6167�1 ll Pllfl/ _� OW � / gw• f/ Notary
My commission expires 1
Pt1J3 00
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