HomeMy WebLinkAboutNCC220573_FRO Submitted_20220127C
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. Faith Church Commercial Development
1. Project Name p
2. Location of land -disturbing activity: County Union City or Township Indian Trail
Highway/Street Faith Church Road Latitude 35004'12"N Longitude 80038'25.9"W
3. Approximate date land -disturbing activity will commence: January 1 , 2019
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.93 acres
6. Amount of fee enclosed: $ 455.00 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
T 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 Johnathan M McCall E-mail Addressjrnccall@carolina-development.com
Telephone 704-774-1964 cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Union Triad Properties, LLC 828-773-8290
Name Telephone Fax Number
613 Euclid Street
Current Mailing Address Current Street Address
Monroe NC 28110
City State Zip City State zip
10. Deed Book No. 07411 Page No. 0662 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.
Faith Commercial Partners, LLC
Name E-mail Address
2627 Brekonridge Centre Drive
Current Mailing Address Current Street Address
Monroe NC 28110
City State Zip City State Zip
Telephone 704-774-1964 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
Current Mailing Address
City
E-mail Address
Current Street Address
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:
Wesley Hinson
whinson@hinsonfaulk.com
Name of Registered Agent E-mail Address
309 Post Office Drive
Current Mailing Address Current Street Address
Indian Trail NC 28079
City State Zip City State Zip
Telephone N/A 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.
Faith Commerical Pa rs L C - G. David Cuthbertson Manager
Type or rint e Title or Authority
10/11/19
Signature _
a Notary Public of the County of
State of North Carolina,
hereby certify that
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Nappeared
personally before me
this day and being
duly sworn acknowledged that the
above form was
executed by him.
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Witness my hand and,notarial seal, this
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