NCC241601_FRO Submitted_20240529

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 and/
or fax information unavailable, place N/A In the blank.)
Part A.1. Protect Name Glory Glo Mountain Christian Retreat Center
2. Location of land-disturbing activity: CountyBurke City or TownshlpMOrgantOn
Highway/Street Devinney Ave Latitude35.77303 Longitude-81.64308
3. Approximate date land-disturbing activity will cornmence:May 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Commercial
5. Total acreage disturbed or uncovered(Including off-site borrow and waste areas):7.79
6. Amount of fee enclosed: $ 800.00 . The application fee of$100.00 per acre
(rounded up to the next acre)is assessed without a ceiling amount(Example: 8.10 ac $900.00).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Byron Martin E-mail [e-mail]
Telephone 82$-408-9580 Cell# 828-408-9580 Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Glory Mountain Ministries 828-408-9580
Name Telephone Fax Number
1616 Huffman Bridge Road 1616 huffman Bridge Road
Current Mailing Address Current Street Address
Morganton NC 28655 Morganton NC 28655
City State Zip City State Zip
10. Deed Book No.22$2 Page No.170 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firms) 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.
Glory Mountain Ministries [e-mail]
Name E-mail Address
2780 Devinney Ave 1616 Huffman Bridge Road
Current Mailing Address Current Street Address
Morganton NC 28655 Morganton NC 28655
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 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:
Byron E. Martin [e-mail]
Name of Registered Agent E-mail Address
1616 Huffman Bridge Road
Current Mailing Address Current Street Address -u
Morganton NC 28655
City Slate Zip City State Zip
Telephone Fax Number n/a
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.
Byron E. Martin Chief Executive Officer
T pe or print name Title or Authority
11,1 1 °G1'114 &yr—, 513 I a f
Sig- .tune Date
i, t P. Q , a Notary Public of the County of Alexander"
State of North Carolina, hereby certify that -Byron Everson I ar f k appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness +hi dre notarial seal, this '4 day of i net7 , 20 ail, .
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d 04.a. My commission expires to 151:10,Q5
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