NCC223981_FRO Submitted_20221206

FINANCIAL RESPONSIBILITY/OWNERSHIP FOR
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Act befoi e this form
and an acceptable erosion and sedimentation control plan have been comp) ted nd 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 Dr the e-mail addres or phone
number is unavailable, place NIA in the blank.)
Part A.
1. Project Name Rogaski Residence Erosion Control Plan
2. Location of land -disturbing activity: County Caldwell City or Township Lovelady!
Highway/Street 49 Peaceful Cove Ct. Latitude(decimal degrees) 35.78350$ ongit de(decirnal degrees)-81.440926
3. Approximate date land -disturbing activity will commence: October 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 0.50
6. Amount of fee enclosed: $ 100 The application fe of $ 00.00 per act(rounded
up to the next acre) is assessed without a ceiling amount (Example_ 8.10-acre application fe( is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ EnclosedI'llNo ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing acti ity:
Name Peter Rogaski E-mail Address homeb undnc grnail.com
Phone: Office # Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Peter Michael Rogaski
Name
110 Imes Ct
Current Mailing Address
Statesville NC 28625
City State Zip
10. Deed Book No. 2050 Page No._
Phone: Office # Mobile #
� 10 Imes Ct
Current Street Address
Statesville NC
City State
1198 Provide a copy f the most curr
Zip
it deed.

Part B.
1. Company(ies) who are financially responsible fol
of all responsible parties on accompanied page_;
an individual(s), the name(s) of the owner(s) may be 1
Peter Michael Rogaski
Company Name
110 Imes Ct
Current Mailing Address
Statesville NC 28625
City State Zip
Phone: Office #
Note: If the Financially Responsible Party is not the
the landowner's signed and dated written consent for
control plan and to conduct the anticipated land distu
2_ (a) If the Financially Responsible Party is a dome;
business registry, give name and street address
Name of Registered Agent
Current Mailing Address
City State Zip
Phone: Office # I
Name of Individual to Contact (if Registered Ageni
(b) If the Financially Responsible Party is not a rE
of the designated North Carolina agent who is reg
Name of Registered Agent
Current Mailing Address
City State Zip
Phone: Office # it
Name of Individual to Contact (if Registered Agent
the land -disturbing activity
(Pr
vide a comprehensive
lis
If the company is a sole pr
prieto
ship or if the lan(lowner(sJ
sted as the financially respc
nsible
party(ies).
homeboundnc@gmail,coin
E-mail Address
110 Imes Ct
Current Street Address
Statesville
NC
28"
{
5
City
Stat
Zip
Mobile # [phone]
owner of the land to be disturbed,
include wi'th
this forrr
the applicant to submit a
draft erosion
and sedi
entatior
rbing activity.
itic company registered cn
the
NC Secretary
of State
:)f the Registered Agent:
E-mail Address
Current Street Address
City
State
Zip
Aobile #
is a company)
sident of North Carolina,
give
name and stree
address
istered on the NC Secret
ry of
State business
registry:
E-mail Address
Current Street Address
City
State
Zip
lobile #
is a company)
11

(c) If the Financially Responsible Party is engaging in business under an a sum d name, give Iname 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 a assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
The above information is true and correct to the best of my knowledge and 1 elief and was provided
by me under oath. (This form must be signed by the Financially Responsible erson if an in ividual(s)
or his attorney -in -fact, or if not an individual, by an officer, director, pariner,r registered agent with
the authority to execute instruments for the Financially Responsible Party). I agree tT provide
corrected information should there be any change in the information pr video herein. I
Peter Rogaski
r print name
Signature
Owner
Title or Authority
Date
I, HaIrici ft-frMa S baniez , a Notary Public of the
State of North Carolina, hereby certify that"�64 ev- en CI()
before me this day and being duly sworn acknowledged that tl`ie above
Witness my hand and notarial seal, this %"�0( day of
MARIA ESTRADA SANTIBANEZ / tary
NOTARY PUBLIC
Iredell County
North Carolina My commission expl
My Commission Expires 8/28/2024
my
appeared personally
executed b himlher.