NCC241652_FRO Submitted_20240611

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Pitt County
7s. "t' •
Planning Department
I+ . ;�! Development Services Building
'16 1717 W. 5th Street
Greenville, North Carolina 27834-1696 James F.Rhodes,AICP
Telephone: [phone] Director
Fax: [phone]
Financial Responsibility/Ownership Form
Soil Erosion and Sedimentation Control Ordinance
No person may initiate any land-disturbing activity on one or more contiguous acres as
covered by the Act before this form and an acceptable erosion and sedimentation control plan
have been completed and approved by the Pitt County Planning Department. (Please type or
print and, if question is not applicable, place N/A in the blank,)
Part A.
1. Project Name AMBROSE BAY SUBDIVISION
2, Location of land-disturbing activity: County Pitt
City or Township WINTERVILLE , and Highway/Street FROG LEVEL Road
3. Approximate date land-disturbing activity will be commenced:MAY 15th,2024
4. Purpose of development(residential, commercial, industrial, etc.):Residential
5. Approximate acreage of land to be disturbed or uncovered: 6
6. Has an erosion and sedimentation control plan been filed? Yes ✓ No
7. Person to contact should sedimentation control issues arise during land-disturbing activity:
Name Chad Grimes Telephone [phone]
8. Landowner(s) of Record(Use blank page to list additional owners):
Grimes Built Construction,LLC
Name(s) Name(s)
1202A East Firetower Road
Current mailing address Street address
Greenville NC 27858
City State Zip City State Zip
9. Recorded in Deed Book No. 4459 Page No, 358
Part B.
1. Person(s) or firm(s) who are financially responsible for this land-disturbing activity (Use
the blank page to list additional persons or firms):
Grimes Built Construction,LLC
Name of person(s)or Firm(s) Name(s)
1202A East Firetower Road
Current mailing address Street Address
Greenville NC 27858
City State Zip City State Zip
252-717-1418
Telephone Telephone

2. (a) If the Financially Responsible Party is a Corporation, give name and street address of
the Registered Agent.
Name(s)
Current mailing address Street Address
City State Zip City State Zip
Telephone Telephone
(b) If the Financially Responsible Party is a Partnership give the name and street address
of each General Partner(Use blank page to list additional partners):
Name(s) Name(s)
Current mailing address Current mailing address
City State Zip City State Zip
Telephone Telephone
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/her attorney-in-fact or if not an individual by an officer, director, partner, or
registered agent with 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.
Chad Grimes Manager
Ty p tin me Title or Authority
t -I` -
Signature Date
I, athOil`r1 f713� ,a Notary Pu l'c of the County of n 4 — State
of North Carolina,hereby certifythat (� Q,d.ZARAfuli )
appeared personally before me this day an being duly sworn acknowledged that the above form
was executed by him.
Witness my hand and notarial seal this h day of. f "`"`" 20 24
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