NCC216885_FRO Submitted_20211210

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 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 and/or fax information
unavailable, place NIA in the blank.)
Part A.
1. Project Name Carbone Residence
2. Location of land -disturbing activity: County Caldwell City or Township Patterson/Yadkin Valley
Highway/Street Hines Branch Rd
Latitude
3. Approximate date land -disturbing activity will co
N 36.094 Longitude W 81.583
Proiect has started
4. Purpose of development (residential, commercial, industrial, institutional, etc.):
Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.5
6. Amount of fee enclosed: $ 195.00 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
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 Jeffery A. Carbone E-mail Address jcarbone@cwgadvisors
Telephone Cell # [phone] Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Jeffery A_ and Shannon M. Carbone [phone]
Name
17337 Wavecrest Ct.
Current Mailing Address
CORNELIUS NC 28031
City
Telephone
17337 Wavecrest Ct.
Current Street Address
CORNELIUS
State Zip City
Fax Number
NC 28031
State Zio
10. Deed Book No. 2011 Page No, 1313 Provide a copy of the most current dead.
1964 6
Part B.
1. Company (ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) if the company or firm is a sole
proprietorship the name of the owner or manager may be listed as the financially responsible party.
Jeffery A. and Shannon M. Carbone icarbone(d-)cwgadvisors _
Name E-mail Address
17337 Wavecrest Ct 17337 Wavecrest Ct.
Current Mailing Address Current Street Address
Cornelius NC 28031 Cornelius NC 28031
City State Zip City State Zip

Telephone
Fax Number
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.
Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Telephone
Fax Number
(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 Dame. If the Financially Responsible Party
is a Corporation, 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
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.
J1r o Owner
Type or t name Title or Authority
/ 2- 12--
<7144� 7
atur Date
I,we- � S 'rtI a Notary Public of the County of [G
State of N rth Carolina, hereby certify that r ftom"t— appeal
personally before me this day and being duly sworn c no edged that the above farm was executed
by him.
Witness my hand and notarial seal, this 77 day of� 20c7- I
TIFFANY WELSHANS GUARINO
NOTARY PUBLIC
Mecklenburg County
Carollna
MyC;ommisson plres My commission expires jI ! LezfP