NCC216894_FRO Submitted_20211214

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 Section, 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 applicable or the e-mail and/
or fax information unavailable, place N/A in the blank.)
Part A. South Main Mixed Use
1. Project Name
2. Location of land -disturbing activity: Countylredell
Highway/Street South Main Street Latitude35.580783
3
4
5
6
rl
City or Township MOOresviIle
Longitude -80.81467
Approximate date land -disturbing activity will commence: l /1 /2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Mixed Use
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.96
Amount of fee enclosed. $ $200 . 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).
Has an erosion and sediment control plan been filed? YesX No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Mike Cassarino E-mail Address [e-mail]
Telephone[phone] cell # 704-907-5984 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
222 South Main, LLC
310-804-2323
Name
Telephone Fax Number
201 N. Church Street
201 N. Church Street
Current Mailing Address
Current Street Address
Mooresville, NC 28115
Mooresville, NC 28115
City State Zip
City State
Zip
10. Deed Book No. Page No.
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.
222 South Main, LLC
[e-mail]
Name
E-mail Address
201 N. Church Street
201 N. Church Street
Current Mailing Address
Current Street Address
Mooresville, NC 28115
Mooresville, NC 28115
City State Zip
City State
Zip
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:
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
corr cted information should there be any change in the information provided herein.
cnce.w.l
Typ or pri name Title or Autho
Sign ure Date
a Notary Public of the County of Ll,,,
State of North Carolina, hereby certify that appeared
personally before me this day and being duly sworn acknowl dged that the above form was
executed by him.
Witness my hand and notarial seal, this day of�Ce��, 20../
Ben J Cassarino
S*TARY PUBUC
Meftnburg County, NC
My Commission Expires September n 2m
Notary
My commission expires��!/%J(,P