NCC224126_FRO Submitted_20221220

FINANCIAL RESPONSIBILITYIOWNERSHIP 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.
1. Project Name TWi n Lakes Lot 15
2. Location of land -disturbing activity: County Union City or Township Matthews
Highway/Street 107 Pecan Cove Latitude35* 01'14"N 8041'47"11V
Longitude
3. Approximate date land -disturbing activity will commence: 12/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 42
6. Amount of fee enclosed: $ 350 The Express Permitting application fee Is a dual charge.
The normal fee of $1oq c) 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 Srinath Musukula E-mail Address [e-mail]
Telephone [phone] Cell # 3345599452 Fax #
a
Landowner(s) of Record (attach accomoanled page to list additional owners):
Srinath Reddy Musukula and Snitha Reddy 3
Prodduturu 345599452
Name
107 Pecan Cove Lane
Current Mailing Address
Weddington, NC 28104
City
State
Telephone
Fax Number
101 Silverspring place
Current Street Address
Mooresville NC 25117
Zip City State
10. Deed Book No, 8479 Page No. 0519
r'
Provide a copy of the most current dead.
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 Rrm is a sole proprletorship,
the name of the owner or manager maybe listed as the financlally rosponslble party.
Srinath Musukula [e-mail]
Name
101 Silverspring Place
Current Mailing Address
Mooresville NC 28117
City State
334-559-9452
E-mail Address
101 Silverspring Place
Current Street Address
Mooresville NC 28117
Zip City
Telephone Fax Number
State
22

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:
nla
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:
nla
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
Steven Prophet 704-882-4222
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.
Srinath Musukula Owner
Type j�
j� o,r, sprint name Title or Authority
Signature Date
I, M' 61 M 6-e W H(�( I , a Notary Public of the County of W h I
State of North Carolina, hereby certify that i,1A appeared personally
before me this dad �Qd��being duly sworn acknowledged that the a ove form was executed by him.
Witness myl?.4 and. ,%i�t;seal, this day of 20 `7-Z
TARY
r Notary
Sep]U S 00 G r
My commission expires Krnf .
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