NCC216901_FRO Submitted_20211214

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FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on % acres as covered by the Act before this form and an
acceptable erosion and sedimentation control plan have been completed and approved by the Macon County
Planning, Permitting and Development. Submit this form to: Macon County Planning, Permitting and
Development 1834 Lakeside Dr. Franklin, NC 28734. (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 Proposed Quick Serve Restaurant
2. Location of land -disturbing activity: County Macon City or Township Franklin
Siler Rd. SR1 660 35d 09m 50.40s N: 83d 22m 15.08s W
Highway/street Latitude Longitude
3. Approximate date land -disturbing activity will commence: f May 1, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): L 2.2
6. Amount of fee enclosed: $ $300.00 1. The application fee of $100,00 per acre
is assessed without a ceiling amount (Example: a 1 acre-$100.00).
7. Has an erosion and sediment control plan been filed? Yes _.1 NoEnclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Mark Tiller 1 E-mail Address [e-mail]
Telephone [phone] Cell # 404-271-0243 Fax # r nla
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Hendon Tiller Franklin, LLC 404-262-7400 nlz
Name Telephone Fax Number
3445 Peachtree Road NE, Suite 465 3445 Peachtree Road NE, Suite 465
Current Mailing Address Current Street Address
Atlanta, GA 30326 Atlanta, GA 30326
City State Zip City State Zip
10. Deed Book No. Page No. Provide a copy of the most current deed.
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.
He Tiller Franklin, LLC [e-mail]
Name E-mail Address
3445 Peachtree Road NE, Suite 465
Current Mailing Address
Atlanta, GA 30326
City State Zip
3445 Peachtree Road NE, Suite 465
Current Street Address
Atlanta, GA 30326
City State Zip
rev 103020

Telephone[phone] Fax Number n!a
(a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
J. Charles Hendon [e-mail]
Name E-mail Address
3445 Peachtree Road Suite 465
Current Mailing Address
Atlanta GA 30326
City State Zip
Telephone [phone]
Current Street Address
City State Zip
Fax Numbe
(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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone I 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.
I Charlie Hendon I Managing Member
Type or print name Title or Authority
May 4, 2021
Date
I, 1 Rcyar'wy__a Notary Public of the County of -Dou
Coco ta.
State of Ne4h-Qk�, hereby certify that 3 - C c.S 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 EEjday of r"\ , 2 Zt
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