NCC230392_FRO Submitted_20230213

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007
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 Environment and Natural Resources. (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.
1. Project Name Bird & Co.
Location of land -disturbing activity: County Davie City or Township_Mocksville
Highway/Street Cooper Creek Road Latitude 35 55' 46" N Longitude 80 35' 51" W
3. Approximate date land -disturbing activity will commence: Oct 01. 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.80 ac
6. Amount of fee enclosed: $ 945.00 , The Express Permitting application fee is a dual charge.
The normal fee of $65.00 per acre is assessed without a ceiling amount. In addition, the Express
Permitting supplement is $250.00 per acre up to eight acres, after which the Express Permitting
supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,586). NOTE: Both fees are
rounded up to the next whole acre and need to be paid by separate checks to NCDENR.
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issueors arise during land -disturbing activity:
Name Brad Chapman E-mail Address bchapmanadavieconstruction.com
Telephone [phone] Cell # [phone] Fax # [phone]
Landowner(s) of Record (attach accompanied page to list additional owners):
Kinqz Properties,LLC. (7041223-0.2.51 _
Name Telephone
157 Buckeye Trail
Current Mailing Address Current Street Address
Mocksville NC 27028
City State Zip City
State
Fax Number
Zip
10, Deed Book No. 1207 Page No. 295 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land4sturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Kingz Properties, LLC
--- ----------------------------
Name
175 Buckeye Trail
Current Mailing Address
Mocksville NC 27028
City State zip
kingg70Dyahoo.com
E-mail Address
Current Street Address
City
Telephone [phone] Fax Number
State
Zip

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
Fax Number
State .Zip
(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:
Tyler King kingg70yahoo.com
Name of Registered Agent E-mail Address
176 Buckeye Trail
Current Mailing Address Current Street Address
Mocksville NC 27028
City State Zip City
Telephone [phone] Fax Number,
State Zip
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
MGES. PLLC [e-mail] _.
Engineering Firm or other consultant E-mail Address
Michael Gunnell [phone]
Individual contact person (type or print) Telephone Fax Number
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 information should there be
any change in the information provided herein.
Tyler King _Manager Partner
Type or print name Title or Authority
iz 9 /{9, /tea
Signature Date
a Notary Public of the County ofStat
before me this dayand being duly sworn acknowledged that the ab v}� w appeared personally
of L North Ca'4ina, hereby _ ��)v r le
g y � c-Uorm was executed by him.
Witness my hand and notarial seal, this[qay of Q 20 1^'.t.
NINA YORK Notary
Nrr��,7jj����yyY PUBUG
YA`H1Fi COUNTY
NORTH CAROUNA My commission expires
My Commis ion Expo s�May ]20n