NCC216809_FRO Submitted_20211209

FINANCIAL RESPPNSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing a ivity on one or more acres as covered by the Act before this
form and an acceptable erosion and s4rn ntation 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 o I print and, if the question is not applicable or the e-mail and/
or fax information unavailable, place NIA in the; blank.)
Part A. Foley Home Sales �LC Property
1. Project Name
2. Location of land -disturbing activity: Cour
Highway/Street Houston Road L
3. Approximate date land -disturbing activity
4. Purpose of development (residential, con
6. Total acreage disturbed or uncovered (in
6. Amount of fee enclosed: $ 300.00
(rounded up to the next acre) is assesses
7. Has an erosion and sediment control plat
8. Person to contact should erosion and sec
Name Doug Foley
Telephone [phone]
9. Landowner(s) of Record (attach accompe.
Foley Home Sales, LLC
Name y
LM5���
Current Mailing Addre s
ylredell city or Township
Troutman
titude 35.6658 Longitude-80.8277
vill commence:12/13/2021
nercial, industrial, institutional, etc.): Residential
uding off -site borrow and waste areas):2.85
. The application fee of $100.00 per acre
without a ceiling amount (Example: 8.10 ac = $900.00).
been filed? YesX No Enclosedx
nent control issues arise during land -disturbing activity:
E-mail Addressfoley1301 @gmail.com
Cell # Fax #
ied page to list additional owners):
856-404-5379
Telephone Fax Number
Current Street Address
City State Zip City State Zip
10. Deed Book No. Page I o. Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are fi
comprehensive list of all responsible pE
the name of the owner or manager may be
Foley Home Sales, LLC
Name
1075 Blue Spruce Drive
Current Mailing Address
Mooresville NC 28115
city
Teleph
State
856-404-5379
ially responsible for the land -disturbing activity (Provide a
on an attached sheet.) If the company or firm is a sole proprietorship,
as the financially responsible party.
[e-mail]
E-mail Address
Current Street Address
City State Zip
Fax Number

2. (a) If the Financially Responsible Party is rot a resident of North Carolina, give name and street address
of the designated North Carolina Agent: II
Name
Current Mailing Address
City
Telephone
State
E-mail Address
Current Street Address
City
Fax Number
State Zip
(b) If the Financially Responsible Party is ` Partnership or other person engaging in business under an
assumed name, attach a copy of the C ificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and stre4 address of the Registered Agent:
Name of Registered Agent
Current Mailing Address
City
T
State
E-mail Address
Current Street Address
City
Fax Number
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 d by the Financially Responsible Person if an individual
or his attorney -in -fact, or if not an individua , by an officer, director, partner, or registered agent with
the authority to execute instruments forte Financially Responsible Person). I agree to provide
corrected information should there be any dpange in the information provided herein.
Doug Foley
Type or rint name
Signature
-------------------------------
1, � JI
President
Title or Authority
12/7/2021
Date
a Notary Public of the County of q�
State of North Carolina, hereby certify that I �
personally before me this day and bein duly
executed by him.
Witness my hand and notarial seal, this
V ISttttp���``'``''%
�G
NO'°Q D aly
�a z
T1 O`i
1XII
'Tv appeared
acknowledgdd that the above form was
ly of P -tO e.r 20. Z j
ary
My commission expires 7-23-�TO�