NCC240279_FRO Submitted_20240221

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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, NC, 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.
1 Project Name t"\, (.5. e 1\ )c.‘„
2. Location of lancl-disttirtfind activity.County City or Township / e
r.
Highway/Street t L0lude 5S6-0 bangilud€.. 2
3. Approximate date!and-disturbina activity will C 0 IT I n it e ----a 7 0 Z I
Purpose of development(residential, commercial, industrial, institutional,etc.): ,L/eir
5, Total acreage disturbed or uncovered (including off-site borrow and waste areas):_ 2 S ,9f,e6-7
3
3, r7 cf7 _
Amount of fee enclosed: $ lhe sore Permitting application fee is a dual
charge. The normal fee of$65.00 per acre (rounded up to the next acre) is assessed without a ceiling
amount. In addition, the Express Permitting supplement is $25(1,00 per acre up to eight acres, after
which the Express Permitting supplemental fee is a fixed$2,000.00 (Example.9 acres total is 52,585)
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 I E-rnall Address. C.:0 ir? Kfriez, 04-7
Telephone L2-5 6.; —'71673 Cell* ('3 3(,)',1"'70 7eilrj5Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
').
461()elle (F_,3 6 )
Name Telephone Fax Number
PO 30
Current Mailing Address Current Street Address
, • ,
o fr37 t1 C 27 3 51
City State Zip City State Zip
10. Deed Book No ,12 411-S par No.//,:; 4),..S Provide a copy of the most current deed
Part G.
1. Company (les) 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 solo
proprietorship, the name of the owner or manager may be listed as the financially responsible party.
,.
Di c
l'eic,t "1"- Lt07.1 p --L_ !,:zci,I 1 kf:•:„ /
Name E-maii Address _f
PO 150 gig
Current Mailing Address Current Street Address
WOO
City State Zip City State Zip

Tole' ht;ll ( .� .76 ) Z_` u c.) f Fax �.ur .lher ytf/,,
-
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:
Name of Registered Agent - r E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
1 ei peon• Fax Number — --- _
(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:
s54GiG�t�S P p 5+i- rl In a,•' a) 1 a I)e�1lftlp�c:r CoM
LA 15e 8a- kl-
Engineering Firm or other consultant EtrrailAddre s
u S Tifl'iP c _,
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.
L-P fZ R`! r2 I WD rn,4 s-- N vy7 4,k./,1�;i(cl_4_ f'r.; / f3 i2.--.
.-;-7 Type or print name Title or Authority
Signature Date
I \-1--D -C-A_C-\-0' LLOK1.11 a Notary Public of the County of f:Yttj td____ 1Z1_
State of North Carolina, hereby certify that /_Ct1'-V�.. -C -QaTh �.`tsm1. appeared personally
before n�e this day and being duly sworn acknowledged : at the above torn;was executed by him.
Witness my hand and notarial seal, this day of_ E-' alb, c{
Notary
ALISHA SICKLAND �1y�
• Notary Public, North Carolina My commission expires \ �__ v �
Davidson County
My Co�IT{1fT(i�$si n x ties
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