NCC223442_FRO Submitted_20221004

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. Golf Village Driving Range
1. Project Name 9 9 9
2. Location of land -disturbing activity: County Mecklenburg
City or Township Pineville
Highway/Street 401 N. Polk St Latitude 35.087 Longitude-80.884
3. Approximate date land -disturbing activity will commence: October 1 , 2022
4.
5.
6.
7.
8.
Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.9
Amount of fee enclosed: $ 600.00 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00),
Has an erosion and sediment control plan been fled? Yes x No Enclosed x
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Nick Mazzella E-mail Address [e-mail]
Telephone [phone]
Cell #
Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Raugh Properties, LLC 828-244-0007
Name Telephone Fax Number
1444 6th St Circle Ct NW 1444 6th St Circle Ct NW
Current Mailing Address
Hickory NC
City State
10. deed Book No. 33668
Current Street Address
28601 Hickory NC 28601
Zip City State Zip
Page No. 427 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.
The Mazzella Partnership
Name
400 Landau Road
Current Mailing Address
Waxhaw NC 28173
City State Zip
Telephone [phone]
E-mail Address
400 Landau Road
Current Street Address
Waxhaw NC 28173
City State Zip
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
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:
Nick Mazzella [e-mail]
Name of Registered Agent E-mail Address
400 Landau Road 400 Landau Road
Current Mailing Address Current Street Address
Waxhaw NC 28173 Waxhaw NC 28173
City State Zip City State Zip
Telephone [phone] 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.
Project Manager
Title or Authority
Date
I, 1 ty)2 5 o yN a Notary Public of the County of jD.Cly—
State of North Carolina, hereby certify that _ .� 1 Uv__ o n?_C happeared
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 &AQu% , 20 �_
Anna B. Simpson
Notary Public, State of South Carolina
i:,y i;ommission Expires March 12, 2030
Seal
A 71 t71/1 2�� /J+✓2
Notary
My commission expires'�Ci�jVl