NCC230232_FRO Submitted_20230127

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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.
1. Project Name Site Development Plan for Szucs Residence
2. Location of land -disturbing activity: County Madison City or Township Mars Hill
Mountain Haven Drive 35.81565-82.52915
Highway/Street Latitude{decimal degrees} LOngltude(decima! degrees)
3. Approximate date land -disturbing activity will commence: JUne, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.94
6. Amount of fee enclosed 1,050.00 . The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition, the Express Permitting supplement is $250 per acre up to eight acres, after which the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900). Checks
should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Aaron Pressley w/Sundog Homes
Phone: Office # 828-768-0060
E-mail Address [e-mail]
Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Jonathan M. & Virginia M. Szucs 828-689-3200
Name
63 Anderson Oaks Drive
Current Mailing Address
Marshall,
City
828-380-9074
Phone: Office # Mobile #
63 Anderson Oaks Drive
Current Street Address
NC 28753 Marshall NC 28753
State Zip
City
State
Zip
10. Deed Book No. 699 Page No. 119 Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -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 owner(s) may be listed as the financially responsible party(ies).
Jonathon M. & Virginia M. Szucs
Company Name
63 Anderson Oaks Drive
Current Mailing Address
Marshall NC 28753
City State Zip
Phone: Office # 828-689-3200
[e-mail]
E-mail Address
63 Anderson Oaks Drive
Current Street Address
Marshall NC 28753
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:
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)
(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 net registered and doing business under an assumed name, attach a copy
of the CW011cate of Assumed Name.
Company aBA Name
(d) If order to facilitate EaprM Permitting, it is necessary to be able to contact The engineer or other
COMultant who can assist In providing any necessary in%mation regarding the plan and its preparation:
Davis CIVIISolu#Ions, P.A.
Engineering film a M iar consultant --
,-Gary P..-Davis, P.E.
Individual Contact parson (fYps or print) -
[e-mail]
E-mail Atldrm
828299-9449 828-713-7334
Phone: Woe # Mobile #
The above information Is true and oDned to the best of my knowledge and belief and was provided
by me under oath. (This form must be signed by the FinancW Responsible lemon if an trxlividual(s)
or his M mey4n-fact, or if not an individual, by an oliiaer, dime Wr, partner, or rsagi*WW agent with
the authority to SWCUte instruments for the Financially Responsible Party). I agree to provide
Corrected information should there be any change in the Information provided herein.
Jonathan & Virginia Szucs
Dlggn
eorntature
Property Owners
Title or Authority
y 7
a Notary Public of the County of..;�d.
State of North Carolina, hereby certify that UMwyn �r „V' , 1% . %Mw 5 ac5appeared personally
befmo me ihle day and bWng dutysmm admowledgad that the AM form was emxm ted by hitrrrher.
Witness my hand and notarial seal, this .Z _ day of . , 20 -
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