NCC216374_FRO Submitted_20211206

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on % 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 NIA in the blank.)
Part A.
1. Project Name 3eQAf9 14Q1_LE—F�- RESWEA/SE
2 Location of land -disturbing activity: County MAC 0 ,V City or Township �FLL.I SA)
Highway/Street �acKY 1'3QAn/(H RPLatitude 'SS- l b3o-+ Longitude — R 3. Z 9 t 4_-�
3. Approximate date land -disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, institutional, etc.): FES1pFNTIAL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1 S
6. Amount of fee enclosed: 3 I 'S4(0 . The application fee of $100.00 per acre
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
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name_ 3 e R" P H OLL.E fi� E-mail Address
Telephone Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
1E-:PND HOLLER
Name Telephone Fax Number
I I (o SQVTHE—IeN 7RNC E-
Current Mailing Address Current Street Address
F2AAIKL.IN NC 25:F3L(
City State Zip City State Zip
10. Deed Book No. Page No. Provide a copy of the most current deed.
Part B,_
1. pany(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.
Name E-mail Address
It(. SGuTHE9AJ TFCI
Current Mailing Address Current Street Address
FRANKL i /1/ A/C 7 $�3
City State zip City State Zip

Telephone _95O - 4 3` �•y g Fax Number.
2. (a) If the Financially Responsible Parry 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 oCertificate roflAssumed Name. engaging
the Financially business
Responsunder
ibfe
assumed name, attach a copy of the
Party is a Corporation, give name and street address of the Registered Agent:
Name of Registered Agent
Current Mailing Address
City
State Zip
E-mail Address
Current Street Address
City State Zip
Telephone Fax Number
The above information is true and correct to the best of my knowledge and belief and was provideu
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.
Type or print name Title or Authority
/ _')_ c` f /2
sig�6ture Date
12 ic ?a r k tf r, a Notary Public of the County of J o
State of North Carolina, hereby certify that S'C /T W Q P 0 1 I 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 day of sc,ol nq �e/ 20 z 1
Notary
5�a1
My commission expires_ 0S-- Ig - ,ZD,2�5