NCC232105_FRO Submitted_20230713

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FINANCIAL RESPONSI.I3lL,ITY/OWNERSHIP STATEMENT
As per 15A NCAC 04B.0I.18—The draft Erosion and Sediment Control Plans will not be approved until
an authorized statement of financial.responsibility and ownership is submitted.
As per GS 113A-54,1(a)-If the applicant is not the owner of the land to be disturbed.,the owner's written.
consent for the applicant to submit a draft Erosion and Sediment Control Plan and to conduwt the
anticipated land-disturbing aotivi.ty must be submitted with this document,
PART A. tp
I. Project Name: 6-4 17 N r 4 r 0111'
2, Physical Address/Location:
Street Address: 1 50 rcr//i'frriYre city:j, y4 3,'a17 State: i L zip.:...
:T ,•ry- 120.,q j
3. Latitude: w (e,(]ea $3.3 Longitude: —7 9 ,Ai 1 tg
4. -Approximate date land-disturbing aetivitywill commence: /r41.,/7-4.4 202-
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5, Purpose of development(residential,commercial,industrial,eta,)
6. Approximate acreage of land to be disturbed or uncovered: ,
7. Landowner(s)of Record(use blank page to list additional owners):
Et11&i C R On- (2.3 v .
Name Name
Current Mailing Address Current Mailing Address
4. E&11 POMi AK' 1726o
City,State,Zip City,State,Zip
336 - 1380
Telephone Number Telephone Number
8. Indicate book and page where deed or instrument is filed.(use blank page to"list additional deeds
or instruments),Provide copies of Deeds with this submittal,
Book • 0057 page 2.ort,.- 2.oi9. --
Book Page
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PART B.
1. Perrsson(s)or firm(s)who are financially responsible for this land-disturbing activity:
E kl )ifl OS LLc
Na ale Name
13° -roy Lo R-VC,
Current Mailing Address Crurent Mailing Address
eo%Nf`- DJC_ 27 24 b
City,State,Zip City,State,Zip
Telephone Number Telephone Number
2. Registered agent,if any,for the person or firm who is financially responsible;
Signature Meiling Address
Printed Name Telephone Number
3. The above information is true and correct to the best of my knowledge and belief and was
provided by•rne under oath. (This form must be signed by the financially responsible person if an
individual,or if not an individual,by an officer,director,partner or attorney-in-fact,or registered
agent with 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.
cro_
Type or Print Nrnie Title of Authority
6S_ c 3. 2«23
rE Date
I, • -6.11.1Q/!g i l�aerri° r ,a Notaiy Public of the County ofundo+Ph ,State of North
Carolina,do hereby certify that Len Val kooL ,appeared personally before me
this day and being duly sworn acknowledged that the above norm was executed by.him.
Witness my hand and notarial seal,this 3 rot day of_ M_T �1 ,20 a S
Notary Public wan a -f) rultA
k '
3 '; ' ., �'" My.commission expires: c .�t O I o 'r
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