NCC220097_FRO Submitted_20220106

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.G. 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 NIA in the blank.)
Part A.
1. Project Name 2067 SIMPLICITY ROAD
2. Location of land -disturbing activity: County^Cabarrus City or Township: CONCORD
Highway/Street 2067 SIMPLICITY RD Latitude N35°33'39" Longitude W-80°54'01"
3. Approximate date land -disturbing activity will commence: November 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.):
RESIDENTIAL STOCKPILE
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 36
6. Amount of fee enclosed. $ 2,340.00 . 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 X Enclosed
8, Person to contact should erosion and sediment control issues arise during land -disturbing activ ty.
Name: Vincent DiPros ero--Sealand Contractors VP E-mail Address: vid@sealat)dcontractors.com
Telephone [phone] Cell # �704-634-7584 Fax # _704-522-5494
9. Landowner(s) of Record (attach accompanied page to list additional owners):
William S & Suzan Craig
Name Telephone Fax Number
2100 Simplicity Rd 2100 Simplicity Rd
Current Mailing Address Current Street Address
Concord _ NC 28205 Concord NC 28205
City State Zip City State Zip
10. Deed Book No. 11813 Page No. 0099_ - _, Provide a copy of the most current deed.
Part B.
1. 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):
Sealand Contractors Corp.
Name
1708 N Caldwell Street
Current Mailing Address
yid0sealandcontractors. cam
E-mail Address
1708 N Caldwell Street _
Current Street Address
Charlotte NC 28206 Charlotte NC 28206 _
City State Zip City State Zip

Telephone [phone] Fax Number 704-522-5494
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 Stale Zip
Telephone
City State
Fax !Number
6WU
(b) If the Financially Responsibly: 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
Current Mailing Address
City State
Telephone
E-mail Address
Current Street Address
Zip City State Zip
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.
Daniel J. Bree _ President _
Type or print name Title or Authority
Sig
11 /01 /2021
Date
i
I, K� CL a Notary Public of the County of Uvi..avi
State of North Carolina, hereby certify that �.'•a 5 • 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 day of 0 00_"6-r , 20 Z (
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