NCC231771_FRO Submitted_20230608

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 Soil Erosion and
Sedimentation Control Ordinance of the City of Greenville (Title 9, Chapter 8) before this form and an
acceptable erosion and sedimentation control plan have been completed and approved by the City of
Greenville, Engineering Division. (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.
1. Project Name Verma House
2. Location of land disturbing activity: County PITT City or Township GREENVILLE
Highway/Street DUNHAGAN ROAD Latitude 35.562180 Longitude-77.381600
3. Approximate date land-disturbing activity will commence:June 1st 2023 - March 31 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Ressidential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):below 0.4 acre
6. Amount of fee enclosed: $40.00 . The application fee of$100.00 per acre (rounded
to the tenth of acre) is assessed without a ceiling amount (Example:a 9-acre application fee is$900).
7. Has an erosion and sediment control plan been filed? Yes Yes No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Anil Dhulia E-mail [e-mail]
Telephone Cell# 919 272 6115 Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Rajesh Verma 2523787475
Name Telephone Fax Number
200 Fosbury Way Apt C 200 Fosbury Way Apt C
Current Mailing Address Current Street Address
GREENVILLE NC 27834 GREENVILLE NC 27834
City State Zip City State Zip
10. Deed Book No.4129 Page No.445 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Rajesh Verma [e-mail]
Name E-mail Address
200 Fosbury Way Apt C 200 Fosbury Way Apt C
Current Mailing Address Current Street Address
Greenville NC 27834 Greenville NC 27834
City State Zip City State Zip
Telephone [phone] Fax Number

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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) If the Financially Responsible Party is a Partner ip or other person engaging in business under an
assumed name, attach a copy of the Certific. • of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street ..dress of the Registered Agent:
Name of Registered Agent E-mail Address
Current Mailing Addre : Current Street Address
City State Zip City State Zip
Tel-= one 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 by any change in the information provided herein.
t2JtM O er OW A kir
Type or print name Title or Authority
SUse+ S'f4 ( 20-3
Signature
Date
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I, UPSS/Ca. eY, k Sin , a Notary Public of the County of akcainot,%
State of North Carolina, hereby certify that ' 3es Varna. appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.Witness my hand and notarial seal, this )Co day of I 1 ,0. , 2O 23
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Jessica D Alston No ry
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North Carolina commission expires
My Commission Expires February 28,2027