NCC243417_FRO Submitted_20241104

Pitt County
( Planning Department
4C
Development Services Building
lei4,4,1,n=7„„e
coo 1717 W. 5th Street
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.
Islamic Hwy 43 Project
1. Project Name
2. Location of land-disturbing activity: County Pitt
City or Township Winterville , and Highway/Street NC Hwy 43 /Charles Blvd
3. Approximate date land-disturbing activity will be commenced:
4. Purpose of development(residential, commercial, industrial, etc.):
Recreational
5. Approximate acreage of land to be disturbed or uncovered: 3.84
6. Has an erosion and sedimentation control plan been filed? Yes No x
7. Person to contact should sedimentation control issues arise during land-disturbing activity:
Name Mohamed Shamseldin Telephone [phone]
8. Landowner(s).of Record (Use blank page to list additional owners):
Islamic Association of Eastern North Carolina
Name(s) Name(s)
1303 S Evans St
Current mailing address Street address
Greenville NC 27858
City State Zip City State Zip
9. Recorded in Deed Book No. 3084 Page No. 247
Part B.
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):
Islamic Association of Eastern North Carolina
Name of person(s)or Firm(s) Name(s)
1303 S Evans Street
Current mailing address Street Address
Greenville,NC 27858
City State Zip City State Zip
252-758-4411
Telephone Telephone

2. (a) If the Financially Responsible Party is a Corporation, give name and street address of
the Registered Agent.
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):
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. i 4
IMohamed Shame Registered Agent
Type Title or Authority
/11440,41- 7 aizeizq
Signature Date
I, MI c-h-e-lic , a Notary Public of the County of p State
of North Carolina, hereby certify that IY\ \r\taffy hoLty)--)eta
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 day of 'Juvve____ . 20
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Notary
My commission expires . -1
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