NCC223507_FRO Submitted_20221012

FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROLACT
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 address or phone number is unavailable, place NIA in the blank.)
Part A.
1. Project Name: Furr Buildings
2. Location of land -disturbing activity: County: Cabamas City or Township: 9 Geo eville
HighwaylStreet: 5955 Hi hwa 200 Latitude: 35.31694° N Longitude 80.4744° W
3. Approximate date land -disturbing activity will commence: August 1. 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.):
commercial
5, Total acreage disturbed or uncovered (including off -site borrow and waste areas): 8.3 ac
(previous 6.1ac1
6. Amount of fee enclosed: $200. The application fee of $100.00 per acre (rounded up to
the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is
$900). Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes rd Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing
activity:
Name: Tim Furr E-mail Address: rossfurr ahoo.com
Phone: Office # Mobile # (704) 7Q1-2$49
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Tim Furr 7( 0 4 )
791-2849
Name Phone: Office # Mobile #
5615 Shoreview Drive 5955 Highway 200
Current Mailing Address Current Street Address
Concord NC 28025 Concord NC
28025
City State Zip City State
Zip
10. Deed Book No.: 11575 Page No.: 257
Deed Book No.: 44283 Page No.: 1Q
Deed Book No.: 13617 Page No.: 2K Provide a copy of the most current deed.

_.. L.I.
9. Company(ies) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on accompanied page.) if the company is a sole
proprietorship or if the landowner(s) is an individual(s), the name(s) of the owner(s) may be listed as the
financially responsible party(ies).
Tim Fury rossfurrQvahoo.com
Company Name E-mail Address
5615 Shoreview Drive 5955 Highway 200
Current Mailing Address Current Street Address
Concord NC 28025 Concord NC
28025
City State Zip City State
Zip
Phone: Office # Mobile #: [phone]
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include
with this form the landowner's signed and dated written consent for the applicant to submit a draft
erosion and sedimentation control plan and to conduct the anticipated land disturbing activity_
2. (a) If the Financially Responsible Parry is a domestic company registered on the NC Secretary
of State
business registry, give name and street address of the Registered Agent:
Name of Registered Agent E-mail Address
Current Mailing Address
City
Zip
Phone
Current Street Address
State Zip City
Office #
--------------------------
Name of Individual to Contact (if Registered Agent is a company)
State
Mobile #
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street
address of the designated North Carolina agent who is registered on the NC Secretary of State
business registry:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address

City State Zip City State
Zip
Phone
office #--—---————————————— — — — — — —
Name of Individual to Contact (it Registered Agent is a company)
Mobile #
(c) If the Financially Responsible Party is engaging in business under an assumed name, give
name under which the company is Doing Business As. It the Financially Responsible Party is an
individual, General Partnership, or other company not registered and doing business under an
assumed name, attach a copy of the Certificate of Assumed Dame_
Company DBA Name
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(s) 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 Party). I agree to provide corrected information should there
be any change in the information provided herein.
Tim Furr
/ 1n2 J ��Jz le 49 to
Type or print name Title or Authority
Sig ature Date
I �e �� re e✓ Yt e , a Notary Public of the County of
State of North Carolina, hereby certify that
u r r appeared personally before me this day and being
duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this day of U 20
Jean Greene Notary
Notary PubUc
Cabarrus County M y c o m m i s s i o n
ex North Carolina
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