NCC216006_FRO Submitted_20211028

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 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 Environment and Natural Resources. (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 Mau nlci o VI -5 +"q L t,+ Deyeko p m 2 v-,�
2. Location of land -disturbing activity: County Bu R V.-E City or Township M oRCx A N r0N
38 24 MouNTAR v I5TA pQIVE
Highway/Street Latitude 3TJ2 i (7 Longitude - gi - 60144 b
3. Approximate date land -disturbing activity will commence: S ep-t' e v`^ 6 e v S d 2. O
4. Purpose of development (residential, commercial, industrial, institutional, etc.): RESk b V K1T 1 A L_
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1 , q
6. Amount of fee enclosed: $ 13 O. 00 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed_V
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameSAMFS E3t? IoC,e5
E-mail Address I6P,d9es 757Z&gr.,ai I - co,'
Telephone 3 0 - 7 & I - q f, 6 S Cell # 30 S-i 61- 9 6& S Fax #
4 A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
3a5 -7't -'SCA0
JAMFSA3R1D6cSiR1NA BAR Vf'S305-7b1-9665 NA
Name Telephone Fax Number
5366 MEA'DOW Mofr YJAy 6366 MEAb0WgP.o FT WAY
Current Mailing Address Current Street Address
FFoRrr MILL SC, 29708 Foe.T /Ntlk SC. 2q"7O8
City State Zip City State Zip
10. Deed Book No. 3 S Page No. t7 ( Provide a copy of the most current deed.
Part B.
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):
TA MES 5RID6 ES + ", rY- �5 7�'�2 motlk.Com
Name PI N A R (3 R. I o G' w,,FE� E-mail Address
5366 MfApowc20FT WAY 5366 WA\j
Current Mailing Address Current Street Address
row% SC 29?11�'B FFOR-r M111 SC, 29`708
City State Zip City State Zip
Telephone305 - -T 6 1 - 1166 5 Fax Number N A

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:
SusAt4 }kA\Q.E SvsC;-t V1 It VAe5 1aZ)0.1
Name E-mail Address
08 lie N. S+efdorij S{.
Current Mailing Address Current Street Address •'
MO✓ClAmiOt4 f�C 286SS MoirQA✓i4Of� iVC 2 ('5
City State Zip City State Zip
Telephone 8 Z-8 - 4 3 -1 - 33 3 5 Fax Number 12� z S - 43 -1 - 9 8 3 2—
(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:
NA
Name of Registered Agent
dA
Current Mailing Address
KA
E-mail Address
Current Street Address
Ni A
City State Zip City
Telephone_N A Fax Number N A
State Zip
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.
Sq."'Es A. 8MV-.
Type or print name Title or Authority
S ature Da4
lAtts Me-)kt�L Cor-E 1' a Notary Public of the County of t0 Ic
State of �Mftrolina, hereby certify that ax ?�t- lams appeared
personally before me this day and being duly sworn ackn ledged that the above form was
executed by him.
Witness my hand and notarial seal, this ' day of ,Se_wNe� 20Q1
Seal
WE CERTIFY THAT THIr
DOCUMENT IS FULL TRUE
AND COMPLETE COPY
OF THE ORIGINAL
Public
State_of
%swm C"'Ai" p
Notary
My commission expires