NCC223911_FRO Submitted_20221128

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 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. Gene Court
1. Project Name
2. Location of land -disturbing activity: County Cabarrus City or Township Concord
Highway/Street Gene Court Latitude N350 24' 58.56" Longitude W80° 33' 42.49"
3. Approximate date land -disturbing activity will commence: 6/ 1 f 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off site borrow and waste areas): 5.247 ^
6. 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).
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 Michael Mitchem E-mail Address [e-mail]
Telephone [phone] Cell # (704) - 458-0975 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to fist additional owners):
Men In Motion Hoare Renovations, LLC
Name
P.O. Box 38858
Current Mailing Address
Charlotte NC 28278
[phone]
Telephone
2807 Whaleys Court
[phone]
Fax Number
Current Street Address
Charlotte NC 28273
City State
Zip
city
state Zip
10. Deed Book No. 14764
Page No.
0092-0093
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 ormanager maybe listed as the financially responsible paq.
Men In Motion Home Renovations, L.LC [e-mail]
Name
P.O. Box 38858
Current Mailing Address
Charlotte NC 28278
city
State Zip
Telephone [phone]
E-mail Address
2807 Whaleys Court
Current Street Address
Charlotte NC 28273
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 E-mail Address
Current Mailing Address Current Street Address
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 City state Zip
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
4be^ any change in the information provided herein.
Type or print name Title or Authority
- _ 11.3. -
�Ci2 --
Signature Date
1
a Notary Public of the County ofAr iikig.;��s_.<
State of North Carolina, hereby certify that " :r1ct�cF i 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 4 day of A41 g,
=E�Qwea
E F
L
Carolina
llotary
23,
My commission expires 2-3 4 .,