NCC224208_FRO Submitted_20221230

}
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 Soil Erosion and
Sedimentation Control Ordinance of the City of Greenville (Title 9, Chapter 8) before this form and an acceptable
erosion and sedimentation control plan have been completed and approved
Engineering Department. (Please type or print and, if the question is not
phone number is unavailable, place N/A in the blank.)
Part A.
by the City of Greenville,
applicable or the e-mail address or
1. Project Name Drs. Davila & Velazquez, P.A. Dental Office Site
2. Location of land -disturbing activity: County Pitt City or Township Greenville
Highway/Street E. Arlington Blvd. Latitude(decimal degrees)35.576494 Longitude(decinial degrees) '77.361663
3. Approximate date land -disturbing activity will commence: October 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2 acres
6. Amount of fee enclosed: $ 200.00 .The application fee of $100-00 per acre or portion
hereof (rounded up to the next acre) is assessed without a ceiling amount (Example.- 8.1 0-acre
application fee is $900).
7. Has an erosion and sediment control plan been filed? Yes E] Enclosed ZI No L-1
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Dr. Norberto Velaz
Phone: Office # 252-756-7789
E-mail Address drvelazquez@mac-com
Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
D & V Commercial Properties, LLC
Name
17f1 ()akmnnt nrivp
252-756-7789
Phone.- Office #
1 Wl C),qkmnnt nrl\/P
252-258-0507
Mobile #

a-����l+s��l!'�ir��`I�.^+::+� n!":!!.F .. lr►�aa�.Y.'�!r+ri 1�-�, a7±*".' `..�cTt'��ls�ltili►t"�r 4**sr��trrs -� -�.� -4..__ _ _ —• --�
Part B.
1. Company(les) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the companyis �� sole proprietorship or if the landowner(s) is
��rl iiidividu��l(s), ffie names) of Me owner(s) may be listed as the financi��lly responsible party(ies).
D & V Commercial Properties, ILLC
Company Name
120 Oakmont Drive
Current Mailing Address
Greenville NC 27858
City State Zip
Phone-. Office # 252-756-7789
[e-mail]
E-mail Address
120 Oakmont Drive
Current Street Address
Greenville NC 27858
City State Zip
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.:
Dr. Norberto Velazquez
Name of Registered Agent
120 Oakmont Drive
Current Mailing Address
Greenville NC 27858
City State Zip
Phone: Office # 252-75&7789
drvelazquez@mac-com
E-mail Address
120 Oakmont Drive
Current Street Address
Greenville NC 27858
City State Zip
Mobile # [phone]
Dr. Norberto Velazquez
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'
N/A
Name of Registered Agent
Currant Mailing Address
E--m,---A Address
Current Street Address
city State Zip City State Zip
Phone: Office #
Mobile !!
Name of Individual to Contact (if Registered Agent is a company)

(c) If tl�e Financially Responsible Party is engaging in business under an assumed name, give name under
\.A111ic11 the conipany is Doing Business As. If the Financially Responsibly 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.
Con�pany DBA Name
The above information is true and correct to the best of my Knowledge and belief and was provided
bN me under oath. (This form must bR signed VFin,--
y the ncially Responsible Person if an individual(s)
or his attorney -in -fact, or if not an individual; by an officer, director.,
the authority to execute instruments for the Financially Responsi
corrected information S hould there be any change in the information
Dr. N
,qAy6rto Velazquez
T �
or print name
J —1
ianature
Owner
Title or Authority
Date
partner, or registered agent with
ble Party). I agree to provide
provided herein.
wwwwwwww wwrrw 8.0f env me o4 meMWMM �Ww Mr s wrr w ON*w www ww ww ww rw ww www•w —r...---------.y�.n.Aw.......rrr.ti....�rr��i.��.�rr��w�tiwawr....wwww�wwr
I a Notary Public of the County of c
State of North Carolina, hereby certify that
before me this day and being duly sworn acknowledged that the above form wa
Witness my hand and notarial seal, this l � day of
Notar
My commission expires
4 �'t *#e,--2
appeared personally
s executed by him/her.
.ti