NCC233107_FRO Submitted_20231018

Check if this project is ARPA-funded ❑
Attach a copy of the Letter of Intent to Fund
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, including any
activity under a common plan of development of this size as covered by the NCGO1 permit, 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.
1. Project Name 200 Kern Street Demolition
*If this project involves American Rescue Plan Act(ARPA) funds, list the Project Name or Project
Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the
Division of Water Infrastructure (DWI).
2. Location of land-disturbing activity: County Davidson City or Township Thomasville
Kern Street 35.88859 -80.07946
Highway/Street Latitude(decimal degrees) Longitude(decimal degrees)
3. Approximate date land-disturbing activity will commence: 10/1/23
4. Purpose of development(residential, commercial, industrial, institutional, etc.): demolition
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1 '85
6. Amount of fee enclosed: $200'00 . 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 ❑ Enclosed ❑✓ No El
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Dustin Allen E-mail Address duStin [e-mail]
Phone: Office# Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
SEE ATTACHED ORDINANCE
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
10. Deed Book No. Page No. 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).
City of Thomasville, NC [e-mail]
Company Name E-mail Address
10 Salem Street
Current Mailing Address Current Street Address
Thomasville, NC 27360
City State Zip City State Zip
Phone: Office# 336-475-4210 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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Name of Individual to Contact (if Registered Agent is a company)
(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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Name of Individual to Contact (if Registered Agent is a company)

(c) If the 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
of the Certificate of Assumed Name.
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
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before me this day and being duly sworn acknowledged that the above form was executed by him/her.
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AN ORDINANCE TO REPAIR OR DEMOLISH UNIT
WHEREAS, Article VII, Section 14.330, of the Code of Ordinances for the City of
Thomasville, North Carolina, Nonresidential Building Maintenance Code, sets forth the
procedures for determining minimum standards of fitness for buildings, and
WHEREAS, Article VII, Section 14.330, of the Code of Ordinances for the City of
Thomasville, North Carolina, sets forth the minimum requirements for buildings or
structures used or intended to be used for human habitation, and
WHEREAS, Faye Thomas, Trustee, is the owner of certain real property located within the
corporate limits of the City of Thomasville, North Carolina, at 200 Kern Street., which is
further described in Parcel Id 16078A0000005, whereon a building is located, and
WHEREAS, the Thomasville Code Enforcement Inspector did on the 8th day of January,
2021, go upon said premises and personally inspect the same, and found said improvements
thereon located to be deteriorated within the meaning of the Thomasville City Code, and
WHEREAS, the Thomasville Code Enforcement Inspector gave notification by certified
mail and posted the property on January 31, 2023, notifying said owner that said inspector
would conduct a hearing to determine the fitness of said building at his office on February
15, 2023, at 10:00 o'clock A.M., and,
WHEREAS, said Inspector was present at the appointed time and place for said hearing and
the owner, Faye Thomas, Trustee, did not appear, and
WHEREAS, said inspector at the aforesaid hearing made a determination that said building
located on the property of said owner is deteriorated and unfit for human habitation, and
made his said findings in writing, and issued and caused to be served upon said owner an

NOW, THEREFORE, BE IT ORDAINED that the Thomasville Code Enforcement Inspector
cause the structure located on the premises of 200 Kern St., which is further described in
Parcel Id 16078A0000005, be closed to occupancy and demolished, and to accept bids for
the demolition at the end of the thirty (30) days if the owner fails to comply with this order.
ADOPTED AND APPROVED by the Thomasville City Council, meeting in Regular
Session this 17`i' day of April 17 2023.
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Mayor
City Clerk
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