NCC232843_FRO Submitted_20230920

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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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Highland Meadows Ridge
2. Location of land-disturbing activity: County Yancey City or Township Burnsville
Cane Branch/Highland Meadows Ridge 35.901 82.232
Highway/Street Latituderded;h,a�degrees) Longftude(decnai degrees)
3. Approximate date land-disturbing activity will commence: December 27, 2021
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):5 acres
6. Amount of fee enclosed: $$1360 . The application fee of$100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes® Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name James R. Sherar E-mail Address [e-mail]
Phone: Office# Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Danielle and Michael Flake 252-341 -0034
Name Phone: Office# Mobile#
75 Fernwood Court 75 Fernwood Court
Current Mailing Address Current Street Address
Bath NC 27808 Bath NC 27808
City State Zip City State Zip
10. Deed Book No.838 Page No.542 Provide a copy of the most current deed.
RE
C' NED
p()LR.UTY SECTiO

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).
Danielle and Michael Flake [e-mail]
Company Name E-mail Address
75 Fernwood Court 75 Fernwood Court
Current Mailing Address Current Street Address
Bath NC 27808 Bath NC 27808
City State Zip City State Zip
Phone: Office# 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 not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Type or print name-3 Title or Authority
!j, % �_ i1 - 3
Signature Date
Vu 1 cJ .. , a Notary Public of the County of + co. i, j► j.
State of North Carolina, hereby certify that IA ICAVe ( V.e. appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this )-- day of AL( ,.;,5 `; , 20
Notary
Seal • ,
My commission expires �'' C! �`]

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Perry and Shawn Adams 910-257-8389
Name Phone: Office# Mobile#
112 Skybrook Drive 112 Skybrook Drive
Current Mailing Address Current Street Address
Holly Springs NC 27540 Holly Springs NC 27540
City State Zip City State Zip
Deed Book No.838 Page No.542 Provide a copy of the most current deed.
Landowner 3 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 4 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City _ State Zip
Deed Book No. Page No. Provide a copy of the most current deed.

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties,
Attach copies of this page as needed to list all financially responsible parties,
Perry and Shawn Adams [e-mail]
Company 2 Name E-mail Address
112 Skybrook Drive 112 Skybrook Drive
Current Mailing Address Current Street Address
Holly Springs NC 27540 Holly Springs NC 27540
City State Zip City State Zip
Phone: Office# Mobile# [phone]
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#

I i

Addendum to FR/O form Part A,Item 9: Landowner of Record Letter of Consent
Landowner of Record Name: Pc In a rid Sha w V) Pick:CMS
Property Tax ID#/PIN: 0 7 9 Cl v 13 '7 5 7050 o
Property Address Line 1: Cavil aara hGk- i i9h fa/A fa d a- " s elei
'`J
Property Address Line 2: Np �City/State/Zip Code: M rn5i 11 -e� / O a o 11`
Applicant submitting plan - must match the financially responsible party named in Part B
Section 1 of the Financial Respons• i ity/Ownership (FR/O) Form:
Dot rile lit a rd rohael Ffa k. 1
Statement of Landowner Consent: In accordance with NCGS 113A-54.1(a), I hereby declare
that I am the owner or legally authorized representative of the owner of the property described
above and provide my consent for the applicant cited above and in Part B of the FR/O form to
submit a draft erosion control plan to the State of North Carolina and to conduct the planned
land-disturbing activities on the property listed above and in Part A of the FR/O form.
PC(Irl AdarlAc
Type or Print Name Title or Authority
S Date
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51.-Na0n09 e , ro_ct, , .CO (Y) 9W - a.51 ~ 83&.1
Email Telephone
RECEIVED
'_AND QUALITY SECTlo
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