NCC220855_FRO Submitted_20220224

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 N/A in the blank.)
Part A. Allison Helms Lot GradingLots 1 - 10
1. Project Name
2. Location of land -disturbing activity: CountyUnlon City or Township Monroe
Highway/Street Corinth Church Rd (SR 1158) Latitude 34.957209 Longitude-80.603261
3. Approximate date land -disturbing activity will commence: Dec 2021 prior to approval
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.6 ac
6. Amount of fee enclosed: $ 700.00 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
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:
NameAllison Helms E-mail Address [e-mail]
Telephone Cell # 704-201-3117 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Allison's Custom Construction, LLC
Name Telephone Fax Number
1317 Helms Short Cut Rd
Current Mailing Address Current Street Address
Monroe, NC 28112
City State Zip City State Zip
10. Deed Book No. 8360 Page No. 0722 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 orfirm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Allison's Custom Construction, LLC [e-mail]
Name E-mail Address
1317 Helms Short Cut Rd
Current Mailing Address
Monroe, NC 28112
City
Current Street Address
State Zip City
Telephone [phone] Fax Number
State
Zip

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 Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Isaac Cody Allison Helms, Jr. [e-mail]
Name of Registered Agent E-mail Address
1317 Helms Short Cut Rd Same
Current Mailing Address Current Street Address
Monroe NC 28112
City State Zip City State Zip
Telephone [phone]
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.
Issac Cody Allison Helms, Jr Manager
Type or print name
Signature
Title or Authority
Date
1, 1P ±t'a� S C fs- , a Notary Public of the County of
State of North Carolina, hereby certify that As-) . 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 ay of 20�_
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otary
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ARY PUBLIC My commission expires
Union County
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I My Commission Jw S. 2023