HomeMy WebLinkAboutNCC230345_FRO Submitted_20230207Sail Erosion and `edinjenlation Conlrol
Financial Re%pon%ihilit%/0-A-ncrship Form
,VOT REQUIRED TO BE CO1lPLF.TT.D FOR RF_VDE\TUL ,COT PE&MI
LEASE. READ Till: F OLLOWE s RtFQN-A l 10n:
1) tba a�.XYltn rn" be stgacd to the p wwev of a .lotar)
:) All lack!-Mmurbe g pernsts are valid (iv up ti (2) years foam the date of i<wance, if cimmmeamm uwraat. the pmn„ nu) the
e>ttcndaf I.v t 2 1 ►can per the cxmb tkvm of the Chatham ('.xaty hull Ers.15i t trki Savitnx'nrstion Ct wrv-1 t)4due2n,.x t•remuntttn
boot, *f c Land-Disurtm t pernat mn the holed for failme a) cevrtiet) vtath the OtdimAk-e If the pMMI to tsva-f►evl. all odw
permits am approvals are Aidmj until the prvr y is Me &pan in cvvwItanre urth Chstham Ctlumy resuhtions. Alsq u"
arrttan fiih.`t a civv] Perwty (fact) can be irmitaW a,Ataa1 the rwcTorty owner and or *MilionsJ feew.%ally m4watthle (wiy (tf an))
frr %kAstimm of the Clsathsra C'NMI) \w) rxow%-m and Sadteseatalk-a Control Ordisw-vc Ibis penalty is up to $40M 00 per viutatim
per tisJ aril is a aca.cat daily fie e•vt� da) else fscpett) is in viateal,ars Inacrfcn S %ith tx lwtpaiing an m%gmtwn can mull m a civic
p+raslty oats.• vtrttsn a vtwvr.
3) The inf.vma ion pnTidcd on thin f wn% a% clue aMl ixwYmi to the binit of nit lntnvkd, v and bt-lset an.1 has proWed by me %hilt
usuler &v th
it Thn Lm n n%w be t,iVx%l b) the prtnvM ouna it an itch► idual. Ifav,asnf by a ctiirir(vaey or ccwporatiag this (mn must be >tpmod
by an ,-Alocr. duccLv, pa uwv, at vwy-to-fsci, cK other rusty, r,dt authvint) k% ezeitide imovments fiw the c%vj%vwion wJ
1.'0aHT4nred b) a .tivmpkte 11%1 ,,1 all putrers, mattagrrts Qsc+ntvn aui rettvserrd apma of the ctvrq+aay ew xwp,"iLm
OWNER OF PROPU k I l :
NanseaaclTitle M,aureen_Lvnch
Cavmp17." (tf 1ic4h4)
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ADDITIONAI. FINANCIALLY RFSPONSIBI,E PARTY (irsny):
I�amc and Titlr.
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N011T11 CAROLINA AGE.NT(if say):
Nanw aw I talc
Compam
St&-Wurr:
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1, Manr",% , a notary Public of ��"t_ County in the Ume:
of Coast:•` 4- do lLemb). certify that Koyre cn l-v�t.ti persotttll)
appeared heron me this day and under oath ack wve lodged reading the inl'cxmzutm aNnv and aci Tw%lcdgW that the
above form %%as evecufed br him tv her A
Vlitrtcss my Iwst1 am] uffieisl scat. this thc__L?-�1 ti,11y of �qja+ .20 ZZ..
NOLIrl Public 11.a%*5j0"v K CC.rL'+,
fir;
My cornmismon cspires_ � 1-6, ZO1.S ;A
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Page 3 of 3 "'�%AL CO .a'P
NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print this form, comp:ete, scan and upload to the electronic NO[
Then, mail the original form to the NC DEh1LR Stormwater Program (with $100 check if poying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6n Floor (Office 640K)
1612 Mail Service Center
Raleigh. NC 27699-1612