NCC223531_FRO Submitted_20221013

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 . ProjectName Crozier Personal Home
2. Location of land -disturbing activity. County Burke City or Township Morganton
Highway/Street 3766 Big Creek Rd Latitude(decimaldegrees) 35.699170 Long ituftt c,maldegree*)-81 606110
3. Approximate date land -disturbing activity will commence: 01/01/22
4. Purpose of development (residential, commercial, industrial, institutional, etc.): residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 0.6
6. Amount of fee enclosed: $ 100.00 . 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 ::1 Enclosed X No ::1
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Bryan Simmons E-mail Addresss: simmonsconstructionanddesigaaol.com
Phone: Office # NIA Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
James and Lindsay CrozierNIA 860-331-1802-
Name Phone: Office # Mobile #
8817 Chagrin Dr. 101 same _as_mailing address
Current Mailing Address Current Street Address
Cornelius NC 28031
City State Zip City State Zip
10 Deed Book No. 2477 Page No. 998 Provide a copy of the most current deed.

Fart B.
1. Company(ies) who are financially responsible forthe 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(les).
Bryan Simmons Custom Homes, Inc, simmonsconstructionanddesign(cDacl.corn_
Company Name E-mail Address
8191-B Deep Water Ln. samaras Mailing Address
Current Mailing Address Current Street Address
_Denver NC 28037 _
City State Zip City
State
Phone: Office # NIA Mobile # [phone]
Zip
Nate: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowners signed and dated written consent forthe 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:
William Bryan Simmons
Name of Registered Agent
8191-B Deep Water Ln.
Current Mailing Address
Deriver NC 28037
City State Zip
simmonsconstructionanddesignOaol.com
E-mail Address
same as maiIng address
Current Street Address
same as mailing address
City State Zip
Phone: Office # NIA 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
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip

(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 Assumes! Name.
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 Financialiy 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.
_William Bryan Simmons BuildiM Contractor
Type or grin m Title
or Authority
17 X a V 1 w
Signs Date
a Notary Public of the County of 1_ k I \f (-� I , )
State of North Carolina, hereby certify that _S appeared personally
before me this day and being duly sworn acknowledged that he above form was executed by him/her
Witness my hand and notarial seal, this _ 1
day of I i LA i 1 20 a �
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Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to fist all landowners.
Landowner 2 of Record:
Lindsay, Crozier 860-331-1802
Name Phone: Office # Mobile #
8817 Chagrin Dr. 101 Same as Mailing Address
Current Mailing Address Current Street Address
Cornelius NC 28031
City State Zip City State Zip
Deed Book No. 2477 Page No. 998 Provide a copy of the most current deed.
Landowner 3 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
City State Zip
Zip
Deed Book No
Page No.
Provide a copy of the most current deed.
Landowner 4 of Record:
Name
Phone: Office # Mobile #
Current Street Address
Current Mailing Address
City State
City State Zip
Zip
❑eed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 5 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State Zip
City State
Zip
Deed Book No
Page No.
Provide a copy of the most current deed.