NCC241437_FRO Submitted_20240515

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FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on '/2 acres as covered by the Act before this form and an
acceptable erosion and sedimentation control plan have been completed and approved by the Macon County
Planning, Permitting and Development. Submit this form to: Macon County Planning, Permitting and
Development 1834 Lakeside Dr. Franklin, NC 28734. (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 , ',�
1. Project Name' otlq D1Jf)J1. Cf I - unt Cit or Townshi f►1 t2. Location o and disturbing activity: Co y (- �� l y p� `(5 IA
Highway/StreetlF{'t JU- Jn j , Latitude! Longitude I
3. Approximate date land-disturbing activity will commence: — 49..±-\.7-- 4
4. Purpose of development(residential, commercial, industrial, institutional, etc.): I lelad"-(1..
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):I J bA- _ 'i
6. Amount of fee enclosed: $ . The application fee of$100.00 per acre
is assessed without a ceiling amount(Example: a 1 cre-$100.00).
7. Has an erosion and sediment control plan been filed? Yes' Nor Enclosed I
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name A 4►1'!Le:. E-mail Address]
Telephone' 2- 3‘91 -�� Cell# ax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
-
,PCMC tAidn - )_g- -q-- ,________
Name j Telephone Fax Number
1[12011: 1C fJ • 15,
Current Mailing Address Current Street Address
61 `VC 2874
Cit State ZipCity State Zip
10. Deed Book Noj Page No. LL 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.
Derrick Wong J [e-mail]
Name E-mail Address
1120 Highlands Rd 1120 Highlands Rd
Current Mailing Address Current Street Address
[ Franklin NC 28734 Franklin NC 28734
City State Zip City State Zip
inm'n

Telephone) Fax Number
2. (a) If the Financialt esponsible Party is not a resident of North Carolina, give name and street address
of the designated Nort rolina Agent:
l I _
Name E-m
Current Mailing Addre Current Street tdr Ss
_ I
Gity State Zip City Sta Zip
828-342-7822
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 esp6i ble
rP�is a Corporation, give name and street address of the Registered Agent: f c
-
Name of Registered Age E-mail Address------
1
Current Mailing Address . Current dress
I := I
City State Zip City State Zip
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.
Periii( 1,./p/7.7s el
Type or print name Title or Authority
I
r
Signature . Date , 2_
I,I -vti • + (2av'✓-'5 , a Notary Public of the County of IA 64-
State of North Carolina, hereby certify that --- -e r'"1'1 e iL- W O \ j appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
ouiiiintio
Witnes��t1 Ipa0t9 )1otarial seal, this 92 day of I_ _CO CAr j , 201 �-L
i '
x Notary Public v'� r
` /� _
__Macon I 7
County E. Not ry
-:,. .. Seal $.P` - -My commission expires I a'-2` ' 1-1