NCC223251_FRO Submitted_20220916

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 N/A in the blank.)
Part A.
1. Project Name 120 Lissara
2. Location of land -disturbing activity: County Forsyth City or Township LeWisvllle
Highway/Street
9217 TullamLatltude(decimal degrees) In. 35.8207-78.6476
Longitude(decimal degrees)
3. Approximate date land -disturbing activity will commence: Sept 30 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): • 1 8
6. Amount of fee enclosed 350 . The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition, the Express Permitting supplement is $250 per acre up to eight acres, afterwhich the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900). Checks
should be addressed to NCDEO.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed 0 No ❑
F
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameBryan Elliott E-mail Address [e-mail]1
Phone: Office # 336-345-3551 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
B Elliott Enterprise Inc. 336-345-3551 336-345-3551
Name Phone: Office # Mobile #
5012 North Hills Dr.
Current Mailing Address Current Street Address
Raleigh NC 27612
City State Zip City State Zip
10. Deed Book No.70 Page No.174 Provide a copy of the most current deed.

Part B.
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 orif the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
B Elliott Enterprise Inc.
Company Name
5012 North Hills Dr.
Current Mailing Address
Raleigh NC 27612
elliotbryan@gmail. corn
E-mail Address
Current Street Address
City State Zip City State Zip
Phone: Office # 336-345-3551 Mobile # [phone]
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:
Bryan Elliott [e-mail]
Name of Registered Agent
5012 North Hills Dr.
Current Mailing Address
Raleigh NC 27612
City State
E-mail Address
Current Street Address
Zip City
State Zip
Phone: Office # 336-345-3551 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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #

Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Engineering firm or other consultant
Individual contact person (type or print)
E-mail Address
Phone: Office # Mobile #
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). I agree to provide
corrected information should there be any change in the information provided herein.
Bryan Elliott
Type or pri t e
Signature
Pres.
Title or Authority
9/8/20
Date
I, ) a(06 P?t`n qlfy , a Notary Public of the County of Wave
State of North Carolina, hereby certify that Repo appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this 1.� day of �t.�Jt;�h;�' , 20 Z z
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