NCC222033_FRO Submitted_20220531

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 Martin Farms Phase 1A & I
2. Location of land -disturbing activity- County
Highway/Street:
Moore
5 Latitude
City or Township Aberdeen
35.14069
Longitude
3. Approximate date land -disturbing activity will commence: January 1, 2021
-79,46046
4. Purpose of development (residential, commercial, industrial, institutional. etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 55 Acs.
6. Amount of fee enclosed: $3,575.00 . 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+
Telephone 9 10 - (p , 1409 Z, Cell #
a
E-mail Address :Z,.-*o^'vt<q�-%C�f-46') L.- �Ur"►
9. Landowner(s) of Record (attach accompanied page to list additional owners).
Martin Farms Development, LLC
Name
Fax #
9(D-t:.Q3�t.ti©9Z
Telephone
Fax Number
34 3� &A,, (LD *'%`_% sLa e
Current Mailing Address Current Street Address
12P +4H NL Z`tCa tz
same
city State Zip City State ZFp
10. Deed Book 5806 Page No. 312-314 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) -
Martin Farms Development, LLC
Name
1)`f;� �_: dwt%rA5 AA
Current Mailin Address
Nc
city
State
Zip
�tJP►n.+oERSo At �.CO r`^
E-mail Address
Same
Current Street Address
Same
City State Zip
Telephone 1 l ()_ 6 3 q _ + o ! . 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 E-mail Address
Current Mailing Address
city state Zip
Telephone
Current Street Address
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 Reg stered Agent
Current Mailing Address
city
Telephone
State
Zip
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 by any change in the information provided herein.
Type ar P int Name + Title or Author.ty
Z S ZC� ZZ
Signature Date
I, *ty C , a Notary Public of the County of
tic :w t,
State of North Carolina, hereby certify that _201c1r� AW-Vaef 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
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gr�pTAR�, m
Seal
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