NCC230032_FRO Submitted_20230111

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 address or phone
number is unavailable. place NA in the blank.)
Part A.
1. Project Name James Brid es Residence
2. Location of land -disturbing activity: County_ Caldwell City or Township Granite Falls
Highway/Street 6020 Rocky Mt Rd Latitude,,j�=-ni d, ,,,, 35.799 Lonaitude;dec,.i degmes)-81.346
3. Approximate date land -disturbing activity will commence: 10/1,2022
4. Purpose of development (residential. commercial. industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 8.17
6. Amount of fee enclosed: $ 900.00 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: S.10-acre applications fee is $900).
Checks should be addressed to NCDEQ.
Irr
8.
im
Has an erosion and sediment control plan been filed? Yes €-i Enclosed DO No Cl
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name_Stan Whittington
Phone: Office # _(828)327-8627
E-maii Address [e-mail]
Mobile
Landowner(s) of Record (attach accompanied page to list additional ov;ners):
James Bridges SZ.16. 3�0- Sc)gQ
Name Phone: Office # Mobile
P.Q. Box 2508
Current Mailing Address
Mor ag nton NC 28680
City State Zip
S`( (,1D SELF ���J
Current Street Address
r
State Z;p
Deed Book No. 2052 Page No, 1946 Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land4sturbing 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).
James Brides
Company Name
P.O, Box 250 Fj
Current Mailing Address
E-mail Address
5760 SEL�4 Z�__ I�Z��
Current Street Address
Morganton NC 28680 t Y_0�— 1_4 (--
City State Zip City State Zip
Phone: Office #
Mobile # D ��
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 Party 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
Current Mailing Address
City
E-mail Address
Current Street Address
State Zip City
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(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
Current Mailing Address
City State Zip
E-mail Address
Current Street Address
City State Zip
Mobile #
Name of Individual to Contact (if Registered Agent is a company)

(c) If the Financially Responsible Party, is -engaging in business under an assumed name. give name under
which the company is Doing Business As. If 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 game.
Company DBA Name
The above information is true and correct to the best of nay 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.
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Type or print name
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mature
Title or Authority
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Date
a Notary Public of the Count, of r
44
State of North Carolina. hereby certify that `1L�� 1 }�I y 1�jS� L 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 Z ' day of 1JL r , 20
ANffl �
Notary
Seat
p 7 A R }- My commission expires 11 z��
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