NCC224201_FRO Submitted_20230111

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 and/
or fax information unavailable, place NIA in the blank.)
Part A. Brinkley Ridge
1. Project Name
2. Location of land -disturbing activity: County Cleveland City or Township Kings Mountain
Highway/Street 1017 Phifer Road Latitude 35.2280647 Longitude-81.376997
1 Approximate date land -disturbing activity will commence:12/01 /2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5, Total acreage disturbed or uncovered (including off -site borrow and waste areas): 52.06
6. Amount of fee enclosed: $ $5,400 (Previously Paid) The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Tommy Leppert E-mail Address [e-mail]
Telephone Cell # (704) 751-711 O Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
BBC Brinkley Ridge, LLC [phone]
Name Telephone Fax Number
7224 Jameson Way Same
Current Mailing Address Current Street Address
Stanley NC 28164 Same
City State Zip City State Zip
10. Deed Book No.1869 Page No. 201 Provide a copy of the most current deed.
Part B.
1. 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.
BBC Brinkley Ridge, LLC [e-mail]
Name
7224 Jameson Way
Current Mailing Address
Stanley NC 28164
City State Zip
Telephone [phone]
E-mail Address
Same
Current Street Address
Same
City State Zip
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
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
City State Zip
Fax Number
(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:
Brian Mahoney/BBC BRINKLEY
Name of Registered Agent
7224 JAMESON WAY
Current Mailing Address
STANLEY NC 28164
City
State Zip
mohob@Llv m
E-mail Address
7224 JAMESON WAY
Current Street Address
STANLEY NC 28164
City
Telephone [phone] Fax Num
State Zip
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 informatio"uld there be any change in the information provided herein.
Brian Maw Manager
Type or
re
Title or Authority
10.31..2022
Date
a Notary Public of the County of
State of W Carolina, hereby certify that U40 � appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this day of __, 20-2,?�
•••'O0AS N.
NOTARY `s Notary
Seal PUBLIC 3
my, My commission expires
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