NCC230998_FRO Submitted_20230418

coU Pitt County
'�� Planning Department
Development Services Building
xo < 1717 W. 5th Street
'111c„90 Greenville, North Carolina 27834-1696 James F.Rhodes,AICP
Telephone: [phone] Director
Fax: [phone]
Financial Responsibility/Ownership Form
Soil Erosion and Sedimentation Control Ordinance
No person may initiate any land-disturbing activity on one or more contiguous acres as
covered by the Act before this form and an acceptable erosion and sedimentation control plan
have been completed and approved by the Pitt County Planning Department. (Please type or
print and, if question is not applicable, place N/A in the blank.)
Part A. 11 ''
1. Project Name fiwas hat' l- yr
2. Location of land-disturbing activity: County ?lit
City or Township A syd eh , and Highway/Street Go u r -y 1-tom e 12d
3. Approximate date land-disturbing activity will be commenced: Fe,bvtitOiY�y F ''
4. Purpose of development(residential, commercial, industrial, etc.): JJ
SIn91e, �ami lu� I/1DYY1P� e y
3-41
5. Approximate acreage of land to be disturbed or uncovered: 1 OIGYeS
6. Has an erosion and sedimentation control plan been filed? Yes V No
7. Person to contact should sedimentation control issues arise during land-disturbing activity:
Name Yl evi v1 1"IudSON Telephone 252- 531- to-1 Z5
8. Landowner(s) of Record(Use blank page to list additional owners):
V cvin Nudsoh SOIYa. Hudson S+even Ch CY1/41 rnl CheYry
Name(s) Name(s)
€I32 NC. 1-t+NY +3 Sout- 31101 Tre11‘S 1 .d-
Current mailing address Street address
CsreenvOUe- plc, 215543 G,Yeerivill N(., 2?8S8
City State Zip City State Zip
9. Recorded in Deed Book No. 2132. Page No. y q 5
Part B. 4 9..1h-of WJay Gco # 8qi I?09 .#e 141
1. Person(s) or firm(s) who are financially responsible for this land-disturbing activity (Use
the blank page to list additional persons or firms):
Ke,vw- Sava kt c1soN Steve►-, Cvyst-oll Clne n/
Name of person(s)or Firm(s) Name(s)
5132 N G H w 4-3 S 311a l TYe11i 5 Vol
Current mailing addres Street Address
&tYeertvlll 21856 Cnreehvil 2'7152
City State Zip City State Zip
262- 631- 1o125 25 Z - 53 l - 219$
Telephone Telephone

2. (a) If the Financially Responsible Party is a Corporation, give name and street address of
the Registered Agent.
N /Pc Nl
Name(s)
Current mailing address Street Address
City State Zip City State Zip
Telephone Telephone
(b) If the Financially Responsible Party is a Partnership give the name and street address
of each General Partner(Use blank page to list additional partners):
N/Pr NJP
Name(s) Name(s)
Current mailing address Current mailing address
City State Zip City State Zip
Telephone Telephone
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/her attorney-in-fact or if not an individual by an officer, director, partner, or
registered agent with 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. ``
�'1�i✓oi.,eis vn Lan
Type o pr'nt name Title or Auth •ity
3 �.3
Signature Date
I, Ctkoc kle 4CF-_ , a Notary Public of the County State
of North Carolina, hereby certi y that
appeared personally before me this day and being duly sworn acknowledged that the above form
was executed by him.
Witness my hand and notarial seal this 10 'day of L h . 20
Notary
My commission expires ‘0313j
RENISE ROCHELLE KEYS
NOTARY PUBLIC
Pitt County, North Carolina
My Commission Expires 6/27/2023

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