NCC232903_FRO Submitted_20230927

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
7 '� i C - c`. .-1 cr
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 N/A in the blank.)
Part A. 1:� �} (�c. ;r '
1. Project Name .526' //. Eqfadte,c
2. Location of land-disturbing activity: County OW of City or Township L:i?�� 1 f 5 7 r v
Highway/Street 5fi1lel8-y QJ Latitude Longitude �L
3. Approximate date land-disturbing activity will commence: aS .504 as 1:3sale y.
4. Purpose of development(residential, commercial,industrial, institutional, etc.): ResjevithAi
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 7 t ',c,
6. Amount of fee enclosed: $ y, . The application fee of$65.00 per acre (rounde j
`d r ter;
up to the next acre)is assessed without a ceiling amount (Example: a 9-acre application fee is$585).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name fe/Vaxi Mt E-mail Address RywA r+1cy@e6ricw. titer
Telephone Cell# 7o 1 goo 5321 Fax#
9. Landowner(s)of Record(attach accompanied page to list additional owners):
/41HC At Pi Pe ' P1redows Lie. 7oyyo©5.3z1
Name Telephone Fax Number
q 605 C.trikef i2J
Current Mailing Address Current Street Address
jMo rl rde l 11/.G. 2; M0
City State Zip City State Zip
10. Deed Book No. Page No. Provide a copy of the most current deed.
Part B.
1. Person(s) or finn(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
mHe eloet Meet oral LLC. fly. plc,ee6`;ck.Cot�i
Name E-mail Address
/6©X C_dlri .r Ku
Current Mailing Address Current Street Address
reortl'OR ✓l/. C . 24'110
City State Zip City State Zip
Telephone lot/ goo ,5,3 21 Fax Number

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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 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:
Nike flues M;ke aMeej 6tic t . 64.1
Name of Registered Agent E-mail Address
/Cod e_arcikorf
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 701/ �,3q O C 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.
Type 6r print name Title or Authority
c/® 27-2o21
Sign re Date
I, l . ¶ \a R\ , a Notary Public of the County of6c
State of North Carolina, hereby certify that r.±)-Q,J2 appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarialma 10,1-1 day of a ;l , 20 al
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NOTARY �� ' �l.
Notary
Seal = PUBLIC
�;� My commission expires \S - C�

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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 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 N/A in the blank.)
Part A. ;.. '�r:c -
1. Project Name .5-ad& Eltacta
2. Location of land-disturbing activity: County 1/01/0y1 City or Township j a`_ - FA 2-r� tf A 1 c5 7
Highway/Street 5HPelrft// /V Latitude Longitude
3. Approximate date land-disturbing activity will commence: as .5004 as iCilfide
4. Purpose of development(residential,commercial,industrial,institutional,etc.): Re // tiai (: ., 5,�R
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): .N
6. Amount of fee enclosed: $ 7. . The application fee of$65.00 per acre (round$d D
up to the next acre)is assessed without a ceiling amount (Example:a 9-acre application fee is$585). -o u
7. Has an erosion and sediment control plan been filed? Yes No Enclosed n
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name if else. E-mail Address . Iyadl 4�ee6rict.coif
Telephone Cell# 7o 4/4o S321 Fax#
9. Landowner(s)of Record(attach accompanied page to list additional owners):
lie At PfPer e ow% L I '. @709 4'oa.f.3Z.1
Name Telephone Fax Number
g4.08 easriker kd
Current Mailing Address Current Street Address
liqofee 6. 27llo
City State Zip City State Zip 3.
10. Deed Book No. Page No. Provide a copy of the most current deed.
Part B.
1 .4-ecgtr :aiveo el;a401 YY •3.T•ohno le •►rile%1To m J tommo tti 4A:von l®746Iry/y/�/� (�
CHARLOTTE NC 2$202'.078 0Q00�0035,,
i CGE HU TLEY CONSTRUCTION
MHC@ PIPER MEADOWS LL` '"`
4608.CARRIKER RD DATE; CHECK NO. AMOUNT
MONROE, NC 28110
5/5/2021 000035 $*******455.00
Four-Hundred Fi f ty-
,, . � __� ----=--==---------- Dollars
Five� and -0�T/1'00= ------------------
PAY
TO THE s 7C ,E_;Q, ;`!_"/:, '',11:',,
ORDER <,:::-:23 ''i'‘!:::-!7i--,-,::-''' ;'r-,!-::';:' :,.-.11\‘',::‘::11''':::',.,. A„......z. /e, "04..4"/7 -: -1:-::1 !-Iz;
OF
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