NCC215535_FRO Submitted_20211007

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007
No person may initiate any land -disturbing activity on one or more acres as covered by the Act 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. (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. Union Mills Retail Store
1. Project Name
2. Location of land -disturbing activity: County Rutherford City or Township Camp Creek
Highway/Street US 221 N Hwy Latitude 35.4910 Longitude-81.9784
3. Approximate date land -disturbing activity will commence: 9/20/2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.19 acres
6. Amount of fee enclosed: $ 945 . The Express Permitting application fee is a dual charge.
The normal fee of $65.00 per acre is assessed without a ceiling amount. In addition, the Express
Permitting supplement is $250.00 per acre up to eight acres, after which the Express Permitting
supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585). NOTE: Both fees are
rounded up to the next whole acre and need to be paid by separate checks to NCDENR.
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 Robert Broadway E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
The Broadway Group, LLC 256-533-7287 256-533-7236
Name Telephone Fax Number
216 Westside Square 216 Westside Square
10
Current Mailing Address
Huntsville, AL 35801
Current Street Address
Huntsville, AL 35801
City State Zip City
Deed Book No. 2051 Page No 1937-1939
State
Zip
Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
The Broadway Group of Alabama, LLC
Name
216 Westside Square
Current Mailing Address
Huntsville, AL 35801
City
State Zip
[e-mail]
E-mail Address
216 Westside Square
Current Street Address
Huntsville, AL 35801
City
State
Telephone [phone] Fax Number 256-533-7236
M

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:
Scott Raines
[e-mail]
Name
E-mail Address
9 SW Pack Square, Suite 210
9 SW Pack Square, Suite 210
Current Mailing Address
Current Street Address
Asheville, NC 28801
Asheville, NC 28801
City State Zip
City State Zip
Telephone [phone]
Fax Number 828-707-9429
(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:
Robert M. Broadway
[e-mail]
Name of Registered Agent
E-mail Address
216 Westside Square
216 Westside Square
Current Mailing Address
Current Street Address
Huntsville, AL 35801
Huntsville, AL 35801
City State Zip
City State Zip
Telephone [phone]
Fax Number 256-533-7236
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Civil Design Concepts, PA [e-mail]
Engineering Firm or other consultant E-mail Address
Benjamin Munn [phone]
Individual contact person (type or print) 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.
dway Member - The Broadway Group, LLC
Title or Authority
9/2/21
Signature— "---------- - ---------Date ----------- ._ --------------------- --------- ---------------- - - ----------------
I. u Oa,/Nootary Public of the County of
On
State of "4"Thereby certify that T-1J,� 1 bM6dWCLW appeared personally
before me this day and being duly sworn acknowledged that the above for as executed by him.
Witness my hand and otffjolefflp is day of 20
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