NCC223216_FRO Submitted_20220914

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 address or phone
number is unavailable, place NIA in the blank.)
Part A.
I. Project NameNew Building for Hope Community Church
2. Location of land -disturbing activity: Count Cleveland City or Township Lawndale
312 E Stage Coach Trail 616896 1246116
Highway/Street Latitude(dectmal degrees) LOngttUde(declmal degrees)
3. Approximate date land -disturbing activity wilt commence: U pon Approval
4. Purpose of development (residential, commercial, Industrial, institutional, etc.):Commereial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):6.0
6. Amount of fee enclosed: $ Submitted with initial application The application fee of $100,00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8,10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes i] Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameChris Greene E-mail Address chris@hokeenterprises,com
Phone: Office # 704-482-0003 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Second BaplislChurch olShelby, NCDBAHope CommunityChumh 704-487-7277 704-466-8640
Name
1114 S Lafayette Street
Phone: Office # Mobile #
1114 S Lafayette Street
Current Mailing Address Current Street Address
Shelby NC 28152 Shelby • NC 28152
City State Zip City State Zip
10. Deed Book No. 1 825 Page No.654 Provide a copy of the most current deed.

17"4 411
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s) Is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(tes).
Second Baptist Church of Shelby, NC
Company Name
1114 S Lafayette Street
Current Mailing Address
Shelby NC 28152
[e-mail]
E-mail Address
1114 S Lafayette Street
Current Street Address
Shelby NC 28152
City State Zip City State
Phone: Office # 704-487-7277 Moblle # 704-466-8640
Zip
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Sandy Skipper Allen, Jr
Name of Registered Agent
1114 S Lafayette Street
Current Mailing Address
Shelby . NC
City
skip @ hopeshel,by.org
E-mail Address
1114 S Lafayette Street
Current Street Address
28152 Shelby
State Zip City
NC 28152
State Zip
Phone: Office # 704-487-7277 Mobile # [phone]
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC. Secretary of State business registry:
Name of Registered Agent
Current Mailing Address
City
Phone: Office #
E-mail Address
Current Street Address
State Zip City State Zip
Mobile #
!Name of Individual to Contact (if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Hope Community Church
Company DBA Name
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(s)
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 Party). 1 agree to provide
corrected information should there be any change in the information provided herein.
Sandy Skipper Allen, Jr
Type or print name
na ure
--------------------------------------------------------------
Lead Pastor
Title or Authority
1- 7
Me
I, A 4LC Y-1/(4 A , a Notary Public of the County of ��1 v h o
State of North Carolina, hereby certify that S,Ad 2n All )t appeared personally
before me this day and being duly sworn acknowle ed that e above form was executed by him/her.
Witness my hand and notarial seal, this day of y ��, 20
Itar�
My commission expires
}� �o