NCC223938_FRO Submitted_20221123

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FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on 1/2 acres as covered by the Act before this form and an
acceptable erosion and sedimentation control plan have been completed and approved by the Macon County
Planning, Permitting and Development. Submit this form to: Macon County Planning, Permitting and
Development 1834 Lakeside Dr Franklin, NC 28734. (Please type or print and, if the question is not
app{icable or the e-mail and/or fax information unavailable, place NIA in the blank.)
Part A.
1Project Name Nicks Road Duplexes
.
2. Location of land -disturbing activity: County Macon City or Township Highlands
Highway/Street Hicks Road Latitude Longitude
3. Approximate date land -disturbing activity will commence: October. 15 2022
4 Purpose of development (residential, commercial, industrial, institutional, etc )
Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
Acres
6. Amount of fee enclosed: $ 200 The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 1 acre-$100.00).
7. Has an erosion and sediment control plan been filed? Yes NoEnclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name E-mail Address
Brett Murphy bmurphy4arrowoodconstruction.com
828-421-1973
Telephone Cell # Fax #
9 Landowner(s) of Record (attach accompanied page to list additional owners):
HM Squared 850-687-4373
Name Telephone Fax Number
580 Falls West ©rive
Current Mailing Address Current Street Address
Highlands, NC 28744
City State Zip City State Zip
10, Deed Book No G 41 Page No. 819 Provide a copy of the most current deed
Part B.
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 or firm is a sole
proprietorship. the name of the owner or manager may be listed as the financially responsible party
LLMV-?14a m s 4r•�.�� . �,u,
Name E-mail Addr ss
b -,
Current Mailing Address Current Street Address
C �3�
City State Zip City State Zip
103020

828-421-2957 _
Telephone _ Fax Number[
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
City State Zip
Telephone
E_-
1 ___7
Current Street Address
City State Zip
Fax Numbe
(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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip` j City State Zip
Telephone I 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.
Brett Murphy President
Type or ame Title or Authority
/DI LA7i
Signa ure Date
a Notary Public of the County of
State of North Carolina, hereby certify that appeared
appeared
personally before me this day and being duly sworn acknowledg d th the above form was
executed by him,,••,__
00— S. wI"''0. N
ss�a�ci'�ittd a! seal, this �� day of , 20®
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