NCC250029_FRO Submitted_20250107

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 Sect.on, 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 appi cable or the e-mail andi
or fax information unavanable place N/A in the blank )
Part A. GOVERNORS CLUB LOT 173
1 Project Name_
2. Location of land-disturbing activity County CHATHAM City or TownshipCHAPEL HILL
Highway/Street GOVERNORS DR Latitude 35.8376 Longitude-79.0557
3. Approximate date land-disturbing activity will commence'02/01 /20255
4_ Purpose of development (residential, commercial, industrial, institutional, etc )• RESIDENTIAL
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas: 0.93
6. Amount of fee enclosed. $ 1 00.00 . 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 X No Enclosed X
8. Person to contact sho.:ld erosion and sediment control issues arise dunng land-disturbing activity.
Name
V E N KATA KALI DIN DI E-mail Address [e-mail]
Telephone [phone] Cell# 919-589-7189 Fax
9. Landowner(s) of Record (attach accompanied page to list additional owners).
Bhavani and Venkata Kalidindi 919-589-7189
Name Telephone Fax Number
8012 wadegreen pl
C.:rent Mailing Address Current Street Address
CA RY. NC. 27519
City State Zip City State Zip
10 Deed Book No 02246 Page No.0108 & 0109 Prov de 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 sneet.) Nthe company or hrm is a sole propnerorsh,p,
the name of the owner or manager may be listed as the financially responsible party
Bhavani and Venkata Kalidindi [e-mail]
Name L-mail Address
8012 WADEGREEN PL
Current Mailing Address Current Street Address
CARY, NC. 27519
City Slate Zip City State Zip
Te,epncne 919-589-7189 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:
Name of Registered Agent E-mail Address
Currert 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
corrected information should there be any change in the information provided herein.
V eA7 \ kq/ 1n ,v ))
Type or print name Title or Authority
�/2'/2y
Signature Date
1� ►�h ^I�►z�u� , a Notary Public of the County of LI.e_
State of North Carolina, hereby certify that i,e_ .. 1`ti0.a% C appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him. 1
Witness my hand and notarial seal, this pZ� day of , 20 a,,L
Deborah H Brown Notary
' NOTARY PUBLIC
~ �iy
a, Lee County, NC My commission expires Oti 11 o ��•
My CoTmiulori Expires Oc,ober 04, 2029