NCC221100_FRO Submitted_20220322

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 NIA in the blank.)
Part A. Beaty Park
1. Project Name
2. Location of land -disturbing activity: County Mecklenburg Cityor Township Davidson
Highway/Street 325 Beaty Street Latitude 35d 30' 30" N Longitude'80d 50' 36" W
I Approximate date land -disturbing activity will commence: December 1, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Municipal Park
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.1
6. Amount of fee enclosed: $ 260 . 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).
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 Leslie Willis E-mail Address [e-mail]
Telephone [phone] Cell # 704-940-9609 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Town of Davidson
704-892-7591
Name
Telephone Fax Number
PO Box 579
216 S. Main Street
Current Mailing Address
Current Street Address
Davidson, NC
28036 Davidson, NC 28036
City State
Zip City State Zip
10. Deed Book No. 5466
Page No.189 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 orfirm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Town of Davidson, Parks and
Rec. Dept.
Name
E-mail Address
PO Box 579
865 South Street
Current Mailing Address
Current Street Address
Davidson, NC
28036 Davidson, NC 28036
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
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
City
Fax Number
State Zip
(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:
Leslie Willis [e-mail]
Name of Registered Agent
PO Box 579
Current Mailing Address
Davidson, NC 28036
City
E-mail Address
865 South Street
Current Street Address
Davidson, NC 28036
State Zip City
Telephone [phone] Fax Number
State Zip
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.
Leslie Willis
Type or print name
Parks and Recreation Director
Title or Authority
Signature Date
I, a Notary Public of the County of MKi,_,,Wi bUY�
State of North Carolina, hereby certify that _ (.P—S I, -e— �Ji t j' S 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 a%_day of Se 20Zj
Elizabeth K Shores Nota
S edsoI a guCounty
North Carolina My commission expires
Commission rArns 19