NCC221627_FRO Submitted_20220427

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. Twin Lakes Lot 32
1. Project Name
2. Location of land -disturbing activity: County Union City or Township Matthews
Highway/street Deodar Cedar Dr. Latitude 35.02156 Longitude -80.69962
3. Approximate date land -disturbing activity will commence: March 28, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): '61
6. Amount of fee enclosed: $ 250 . 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.
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 Uma Kasireddy and Sridhar E-mail [e-mail]
Telephone [phone] cell # Fax # n/a
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Uma Kasireddy & Sridhar Chagari 203-631-3087 n/a
Name Telephone Fax Number
906 Deodar Cedar Dr. 906 Deodar Cedar Dr.
Current Mailing Address Current Street Address
Matthews NC 28104 Matthews NC 28104
City State Zip City State Zip
10. Deed Book No. 8337 Page No. 0883 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.
Uma Kasireddy & Sridhar Chagari [e-mail]
Name
2111 Stevens Mill Rd.
Current Mailing Address
City
Matthews NC 28104
State Zip
E-mail Address
2111 Stevens Mill Rd.
Current Street Address
Matthews NC 28104
City State Zip
Telephone [phone] Fax Number n/a

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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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:
Eagle Engineering, Inc. [e-mail]
Engineering Firm or other consultant E-mail Address
Brice Dimitruk 704-315-5734 1-866-775-0329
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.
UMA KASIREDDY AND SRIDHAR CHAGARI Owners
Type or print narT e
J
g Sinature/�/`e
Title or Authority
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Date
a Notary Public of the County of Uy) i Ur 1
State of North Carolina, hereby certify that VIVYIC�)�GS YP dl1-t-St- dh Y Chlaua (1 appeared personally
before me this day and being duly sworn acknowledged that t e above form was;executed by him.
Witness my hand and notarial seal, thisr ,day of r r it , 20 Z2—
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T b'th tary
LUnion
ihelte Exumr`Nb PUBLIC My commission expires0 212 2®2 County, North Carolina
ission Expires 02/12/2024