NCC230444_FRO Submitted_20230215

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 N/A in the blank.)
Part A. Safehouse Subdivision
1. Project Name
2. Location of land -disturbing activity: County Union City or Township Monroe
Highway/Street Hwy 200 Latitude34.927740 Longitude-80.594536
3. Approximate date land -disturbing activity will commence: Sept. 1 , 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 13.08
6. Amount of fee enclosed: $ 1400 . 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 Ingram Walters E-mail Address [e-mail]
Telephone [phone] cell # Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Westside Partners Developers, LLC 704.292.7447 800.954.0823
Name Telephone Fax Number
PO Box 1561 3220 West Hwy 74
Current Mailing Address Current Street Address
Monroe, NC 28110-8431 Monroe, NC 28110-8431
City State Zip City State Zip
10. Deed Book No. 8045 Page No. 0050 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.
Westside Partners Developers, LLC [e-mail]
Name E-mail Address
3220 West Hwy 74 3220 West Hwy 74
Current Mailing Address Current Street Address
Monroe, NC 28110 Monroe, NC 28111-1561
City State Zip City State Zip
Telephone [phone] Fax Number 800.954.0823

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:
N/A
Name
E-mail Address
N/A
Current Mailing Address
Current Street Address
N/A
City State Zip
City State Zip
Telephone N/A
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:
Dave Sierk
[e-mail]
Name of Registered Agent
E-mail Address
3220 West Hwy 74
3220 West Hwy 74
Current Mailing Address
Current Street Address
Monroe NC 28110
Monroe NC 28110
City State Zip
City State Zip
Telephone N/A 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.
Ingram Walters
Member -manager & Organizer
Type or prin ame Title or Authority
01-21-202-2
Signature Date
I, AnnatiAa �- Mom« , a Notary Public of the County of UkYl i on
State of North Carolina, hereby certify that I Irl ca"" wai-�CrS appeared
personally before me this day and being duly swbrn acknowledged that the above form was
executed by him.
Witness my,,ha K aigd.n otarial seal, this
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