NCC242838_FRO Submitted_20240916

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 Soil Erosion and
Sedimentation Control Ordinance of the City of Greenville (Title 9, Chapter 8) before this form and an
acceptable erosion and sedimentation control plan have been completed and approved by the City of
Greenville, Engineering Division. (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 301. A 4 A Sarah Pt.beact (fs
2. Location of land-disturbing activity: County pm- City or Township G reefii Ile,
Latitude ,
H ighway/Street (�t h ��G( � �� 5 6-�,5 Longitude -7 7, y yd,..),
3. Approximate date land-disturbing activity will commence: q! ) /77 Li
4. Purpose of development(residenti I, commercial, industrial, institutional, etc.): As,ci0.h -1
5. Total acreage disturbed or uncove ed (including off-site borrow and waste areas): o v,,
6. Amount of fee enclosed: $ . The application fee of$100.00 per acre (rounded
to the tenth of acre) is assessed without a ceiling amount (Example:a 9-acre application fee is$900).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed (-"
8. Person to contact should erosion a d sediment control issues arise during land-disturbing activi
Name/I/ eft) &ice Co ?]<)-1t E-mail Address CCi t e CUf.Srr'E.fi�1 G f r, i 1.EOM
Tele honecSa'")/`1 c/J N/A IV/ f
P Cell# Fax# /r�
9. Landowner(s) of Record (attach accompanied page to list additional owners):
//?Q.14J/lt?SA) l ^ace ( s i J . 075c1-71 G/- tiqj 3 kJ id
Name Telephone Fax Number
kze A ODA Litt 4e CV. t-6i0 '9Iivn v; IU(c e .
Current Mailing Address Current Street Address
Gre en ti; lie JVC- 173S8 5ceenti; 1le_ A)L Q27g5g
City State Zip City State Zip
10. Deed Book No. Ci I Page No. /50 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsibl parties on an attached sheet):
g 1 die„,, ace: tic en ,The, CacccOas e±/1 G— i'la i I ,awl
Name Email Address `�
/ 0 //1 Vllcte, QC
Current Mailing Address Current Street Address
green 0) I1@. L 02 7g5g
City State Zip City State Zip
Telephone'7/1. L/icl 3 Fax Number

2. (a) If the Financially Responsible P rty is not a resident of North Carolina, give name and street address
of the designated North Carolina Ag nt:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) If the Financially Responsible P rty is a Partnership or other person engaging in business under an
assumed name, attach a copy of he Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name a d street address of the Registered Agent:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
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 ilcor a .tLe�d information should there by any change in th information provided herein.
hew 6. 6-race____ ..
Ty e or pr'nt name Title or Authority
4 g-,72-0 9
ignature Date
I, P1imie M. r15e , a Notary Public of the County of F•}t
State of North Carolina, hereby certify that it41 fitl,,4w B, G re,c-e_ appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this 27 day of Aorst' , 20 2-1
P•'' OT •' �G�. Notary
93,,....,A:, t
Seal • • 17:4—....„
: N q-71... : Y
T.
aComm.r..,._ s• . My commission expires .JL vs+ 1/, tr/L
_ Aug(' •11,2027
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