NCC217103_FRO Submitted_20211222

FINANCIAL RESPONSIBILITYIOWNERSHIP 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. Gem Street Extension
1. Project Name
2. Location of land -disturbing activity: County Mecklenburg City or Township Cornelius
Highway/Street Oak Street Latitude 35.47990 Longitude-80.85938
3. Approximate date land -disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Municipal
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.9
B. Amount of fee enclosed: $ 260 . 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 X Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Tyler Beardsley E-mail Address [e-mail]
Telephone [phone] ext. 172 Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners): See Page 3 for additional owners
Town of Cornelius 704-892-6031 ext. 172
Name
PO Box 399
Current Mailing Address
Cornelius NC
City State
10. Deed Book No. 000000
Telephone Fax Number
21445 Catawba Avenue
Current Street Address
28031 Cornelius NC 28031
Zip City State Zip
Page No. 00000 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 maybe listed as the financially responsible party.
Town of Cornelius
Aba4s e4cayt(, )S. �r
Name E-mail Address
PO Box 399 21445 Catawba Avenue
Current Mailing Address Current Street Address
Cornelius NC 28031 Cornelius NC 28031
City State Zip City State Zip
Telephone [phone] ext. 172 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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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 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 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.
9EP'V:b5L'~_Y Ass'(�mi Town gavt
Type or -print name Title or Authority
Apiri l St 2U21 T
Sig atu Date
I, Jtu+nn -' r S &iw51L1 a Notary Public of the County of Mccac�enb"�
State of North Carolina, hereby certify that jL'r &_Carti,S\ r;" appeared
personally before me this day and being d Iu y sworn acknowledgecr that the above form was
executed by him.
Witness my hand and notarial seal, this 5t�' day of 20 a
�ttttilililiJ!!/fj
ER soft
Notary
uJ Nolary PuLC is IP
County — My commission expires_.Ncr4ember a'1, 9091
My Comm. tp
y 11-27-2021
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