NCC231106_FRO Submitted_20230425

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FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on 1/2 acres as covered by the Act before this form and an
acceptable erosion and sedimentation control plan have been completed and approved by the Macon County
Planning, Permitting and Development. Submit this form to: Macon County Planning, Permitting and
Development 1834 Lakeside Dr. Franklin, NC 28734. (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 324 Industrial Park Rd - Franklin
2. Location of land-disturbing activity: County Macon City or Township Franklin
Highway/Street 324 Industrial Park Rd Latitude_ Longitude
3. Approximate date land-disturbing activity will commence: TBD
4. Purpose of development(residential, commercial, industrial, institutional, etc.): industrial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 0.78
6. Amount of fee enclosed: $ . The application fee of$100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 1 acre -$100.00).
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 Joshua Enot E-mail Address_ [e-mail]
Telephone I 407-898-1511 Cell # - Fax# -
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Mirtek Properties J
Name Telephone Fax Number
277 Industrial Park Road 324 Industrial Park Road
Current Mailing Address Current Street Address
Franklin, NC 28734 Franklin, NC, 28734
City State Zip City State Zip
i
10. Deed Book No. J-37 Page No. 265 1 Provide a copy of the most current deed.
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.
Skanska USA Building [e-mail]
Name E-mail Address
221 Yale Ave N Suite 400 I 221 Yale Ave N Suite 400
Current Mailing Address Current Street Address
Seattle,WA 98109 Seattle,WA 98109 T
City State Zip City State Zip
rev 103020

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:
Skanska USA Building [e-mail]
Name E-mail Address
389 Interpace Pkwy,5th Floor 389 Interpace Pkwy,5th Floor
Current Mailing Address Current Street Address
Parsippany, NJ 07054-1132 Parsippany, NJ 07054-1132
City State Zip City State Zip
813 281 3243
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.
Genevieve Maloney Project Manager
Type or n I Title or Authority
r i1ia� 5/1 Ze7Y7_
Si• . ire I I Date
I, ThV) V i �M c c c'! , a Notary Public of the County of kI 1 V19 j
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State of N , hereby certify that, C.Je-46til['lJed M01.1D/IeLl appeared
personally before me this day and being duly sworn acknowledged tM,t the above form was
executed by him. nn
Witness
``nr Aftly aria) seal, this \ I day of I IV ► , 20 Z Z
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