NCC221125_FRO Submitted_20220413

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 N/A in the blank.)
Part A. CMH Baker Drive Subdivision
1. Project Name
Burke City orTownshi Valdese
2. Location of land -disturbing activity: County Y Township
Valdese
4265 Baker Wive Latitude 35.75118406643615 Longitude-81.58651152931819
3. Approximate date land -disturbing activity will commence: 1 1 /1 /21
4. Purpose of development (residential, commercial, industrial, institutional, etc.):Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
2.7 Acres
6. Amount of fee enclosed: $1 %J . 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 EnclosedX
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name
Larry Carter E-mail Address [e-mail]
Telephone [phone] ext.5660 Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Michael And Timothy Baker
Name Telephone Fax Number
2627 BYRD RD
Current Mailing Address Current Street Address
MORGANTON NC 28655
City State Zip City State Zip
10. Deed Book No.001 531 Page No.00480 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.
CMH Homes, Inc. [e-mail]
N E-mail Address
ame
5000 Clayton Road
Current Mailing Address
Maryville, TN 37804
City State Zip
Telephone[phone] ext.5660
Current Street Address
City
Fax Number
State
M

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:
CT Corporation System
Name E-mail Address
160 Mine Lake Ct Ste 200
Current Mailing Address Current Street Address
Raleigh, NC 27615-6417
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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip
Telephone
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. mA � t' ks
Type
Title or Authority
(OZ� 21
Date
Y►.k a Notary Public of the County of
I-ey\VVs s-Qe- II
State of hereby certify that l a V c& ( appeared
personally before me this day and being duly sw rn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this Z� day of 'r�� � 20 2
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