HomeMy WebLinkAboutNCC230204_FRO Submitted_20230124FINANCIAL RESPONSIBILITYIOWNERSHIP 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.
Batty Plumbing
1. Project Name
Davidson Thomasville
2. Location of land -disturbing activity: County City or Township
Kendall Mill Road 35.851770-80.096420
Highway/Street Latitude(d k,,,,, ,1 Longitudew,a,, ,,
November 30,2022
3. Approximate date land -disturbing activity will commence:
Commercial
4. Purpose of development (residential, commercial, industrial, institutional, etc.):'
3.72
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
400.00
6. Amount of fee enclosed: $ 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 ❑ Enclosed ® No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Brian Deweese bdeweese1972@gmaii.com
Name E-mail Address
336-345-1518
Phone: Office #
Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
MC Investments of Thomasville, LLC 336-345-1518
Name
.210 Gleason Lane
Current Mailing Address
Thomasville, NC 27360
City
State Zip
2523
Phone: Office # Mobile #
Current Street Address
City State Zip
288
10. Deed Book No. Page No. Provide a copy of the most current deed.
t
Part B.
1. Company(ies) who are financially responsible for the Iand-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 owners) may be listed as the financially responsible party(les).
Brain Deweese
MC Investments of Thomasville, Inc. tdbaityplumbing@gmail.com
Company Name E-mail Address
210 Gleason Lane
Current Mailing Address Current Street Address
Thomasville, NC 27360
City State Zip City State Zip
336-345-1518
Phone: Office # Mobile #
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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
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 State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
r
(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 Assumed Name.
Company DI3A 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 Financially 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).
agree to provide corrected information should there be any change in the information provided
herein.
Brian Deweese
Type or print name
Signature
Owner
Fitle or Authority
Date
I, a Notary Public of the County of fAstin
-_-_________
State of North Carolina, hereby certify that .!� appeared
personally before me this day and being duly swam acknow edged that the above form was
executed by him/her.
Witness my hand and notarial seal, this _day of_ e—ejMbpl �t 2022.
gANNANotaryM commission expireY