NCC230285_FRO Submitted_20230207

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
may initiate any land -disturbing activity on one or more acres as covered by the Act before this form
,cceptable erosion and sedimentation control plan have been completed and approved by the Land
Section, N.C. Department of Environmental Quality. Submit the completed form to the appropriate
.ial Office. (Please type or print and, if the question is not applicable or the e-mail address or phone
aer is unavailable, place NIA in the blank.)
art A.
Project Name Chevrolet Dealership
2. Location of land -disturbing activity: County Watauga _ City or Township New River
Highway/Street US 421 South Latitude(decimar degrees) 36.2221651 LongitUde(decimai degrees) 81.6136119
3. Approximate date land -disturbing activity will commence:12101/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 11.62 acres
6. Amount of fee enclosed: $1,800.00. The application fee of $150.00 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 Watauga County Planning & Inspections.
7. Has an erosion and sediment control plan been filed? Yes N Enclosed N No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jordan Mattar E-mail Address imattar v cbuilders.com
Phone: Office # 828-295-0700 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Kristin Dillard
Team Chevrolet Buick GMC of Boone
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
125 FloNid Smooth Office Park Drive 125 Floyd Smooth Office Park Drive
City State Zip City State Zip
Charlotte NC 28262 Charlotte NC 28262
10. Deed Book No. Page No. Provide a copy of the most current deed,

Part B.
1. 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).
VPC Builders LLC
Company Name
2059 Tvnecastle Hwy
Current Mailing Address
city State zip
Banner Elk NC 28604
[e-mail]
E-mail Address
2059 Tynecastle Hwy
Current Street Address
City State Zip
Banner Elk NC 28604
Phone: Office 828-295-0700 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 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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(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
Phone: Office #
E-mail Address
Current Street Address
State Zip City State Zip
Mobile #
Name of Individual to Contact (if Registered Agent is a company)

.ne Financially Responsible Party is engaging in business under an assumed name, give name under
;h the company is Doing Business As. If the Financially Responsible Party is an individual, General
,rtnership, or other company not registered and doing business under an assumed name, attach a copy
A the Certificate of Assumed Name.
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.
Jordan D
Type or print
nature
Promect Manager
Title or Authority
11—f- _
Date
I, n & "tV4 a Notary Public of the County of
State of North Carolina, hereby certify that_... arclanl) M140 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 JJoue &e,' , 20 Q2
`1 mAa. A, PcaTytoatf
=Comm,"
dmond Notary IJ
BLIC
my
ounty My commission expires i i-O(o'aoAco
lina
ovember fi, 2026

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
City State Zip
Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 3 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
City State Zip
Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 4 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State Zip City
Deed Book No. Page No.
Landowner 5 of Record:
State Zip
Provide a copy of the most current deed.
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.