NCC230643_FRO Submitted_20230310

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 N/A in the blank.)
Part A.
Project Name Arbor Domus Treehouse Development
Location of land -disturbing activity: County Watauga City or Township Watauga
Highway/Street Clarks Creek Road Latltude(decimai degrees) 36.1705 Longitude(decimai degrees)-81.7683
Approximate date land -disturbing activity will commence: February 1, 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.11acres
6. Amount of fee enclosed: $ 450.00. 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 ❑x Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jacob VanBuren E-mail Address jacobhowardconstruction(a-)-pmail.com
Phone: Office # Mobile # [phone]
Landowner(s) of Record (attach accompanied page to list additional owners):
Niemyski Family Trust [phone]
Name Phone: Office # Mobile #
6902 Lakeshore Drive Same
Current Mailing Address Current Street Address
Dallas TX 75214
City State Zip City State Zip
10. Deed Book No. 2197 Page No.300 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).
Treehouse Luxe, LLC
Company Name
6902 Lakeshore Drive
Current Mailing Address
Dallas TX 75214
City State Zip
paulniemyski(@gmail.com
E-mail Address
6902 Lakeshore Drive
Current Street Address
Dallas TX 75214
City State Zip
Phone: Office # [phone] Mobile #
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
E-mail Address
Current Street Address
City 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:
Capitol Corporate Services, Inc.
Name of Registered Agent
176 Mine Lake Ct Suite 100
[e-mail]
E-mail Address
Current Mailing Address Current Street Address
Raleigh NC 27615
City State Zip City
Phone: Office # 800-345-4647 Mobile #
Brian Radecki
Name of Individual to Contact (if Registered Agent is a company)
State Zip

(c)Uthe 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
mfthe Certificate mf Assumed Name.
Company DBA Name
The above information is true and correct to the best of0Vknowledge 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, O[ifnot an individual, by an Officer, director, partner, Or registered agent with
the authority to execute instruments for the Financially Responsible Party). | agree to provide
corrected information should there be any change iDthe information provided herein,
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Type or R�yt name
gnature
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Title or Authority
i m Notary Public ofthe County of
State ofNorth Carolina, hereby certify that 1-/auj tJ1g-ML4<'k-; appeared personally
before me this day and being duly sworn acknowledged that the aeove form was executed by him/her.
Witness rnyhand and notarial seal, this of
- =NOTARY PUBLIC Notary
,Watauga County
19volth Carolina
Y Commission Expires November6,2026 My commission expires