NCC250794_FRO Submitted_20250318

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FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on 1/2 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.
1. Project Name Dollar General-Franklin Store#31019
2. Location of land-disturbing activity: County_ Macon City or Township Franklin
Highway/Street-- TBD Sylva Road Latitude 35.235490 Longitude -83.343081
3. Approximate date land-disturbing activity will commence: May 2025
4. Purpose of development(residential, commercial, industrial, institutional, etc.): _ Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2.27 acres
6. Amount of fee enclosed: $ 300.00 . The application fee of$100.00 per acre MOS
is assessed without a ceiling amount(Example: a 1 acre-$100.00).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed_ X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Daniel Almazan E-mail Address [e-mail]
Telephone_ 980-432-8040 Cell# - Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Shawn Pack
Name Telephone Fax Number
80 Davis Lane 80 Davis Lane
Current Mailing Address Current Street Address
Franklin,NC 28734 Franklin,NC 28734
City State Zip City State Zip
10. Deed Book No. J-34 Page No. 668 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.
Teramore Development,LLC [e-mail]
Name E-mail Address
165 Big Star Drive 165 Big Star Drive
Current Mailing Address Current Street Address
Thomasville,GA 31758 Thomasville,GA 31758
City State Zip City State Zip
rev 103020

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:
David Hilton [e-mail]
Name of Registered Agent E-mail Address
7320 Six Forks Road-Suite 100 7320 Six Forks Road-Suite 100
Current Mailing Address Current Street Address
Raleigh,NC 27615 Raleigh,NC 27615
City State Zip City State Zip
Telephone [phone] 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 inform t n should there be any change in the information provided herein.
s,/Huf et r Manager
Type or print nfa Title or Authority
V/c3
Signature Date
I, rf 101(j , a Notary Public of the County of lac VIM)N State of N Y 1'� J, hereby certify that lei . r t C.I v ' -
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 ay of F0,1M , 20 7 S
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