NCC230377_FRO Submitted_20230209

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 and/or fax information
unavailable, place N/A in the blank.)
Part A.
1. Project Name Viens Residence — Lake House
2. Location of land -disturbing activity: County Montgomery City or Township New
London
Highway/Street Southpoint Lane Latitude: 35.4545826' Longitude:-80.1023315'
3. Approximate date land -disturbing activity will commence: 1 /16/2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.39 acres
6. Amount of fee enclosed: $300. 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 No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jamie Moore E-mail Address iamieCa�mooresgrading.com
Telephone [phone] Cell # [phone] Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Nicholas A. Viens [phone]
Name Telephone
1200 Pinehurst Drive 1200 Pinehurst Drive
Current Mailing Address Current Street Address
Chapel Hill NC
City State
10. Deed Book No. N/A Page No. N/A
Fax Number
27517 Chapel Hill NC 27517
Zip City State
Provide a copy of the most current deed.
Zip

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 or manager may be listed as the financially responsible party.
Nicholas A. Veins Nicholas.a.viensa-icloud.com
Name E-mail Address
1200 Pinehurst Drive 1200 Pinehurst Drive
Current Mailing Address Current Street Address
Chapel Hill NC 27517 Chapel Hill NC 27517
City State Zip City State Zip
Telephone [phone] 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:
N/A
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 be any change in the information provided herein.
Nicholas A. Viens & Lindsey K. Viens
Type_or print name
Signature
Property Owner
Title or Authority
g 131 I x)-U
Date
a Notary Public of the County of D, , r fr►�_,,•,
State of North Carolina, herb certify that hi, cki,ug A Vims*- LiAdaN k. weAAS appeared
personally before me this day and being duly sworn acknowledged thatIMe above form was executed
by him.
Witness my hand and notarial seal, this day of fUG' I 20 Z�
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