NCC221337_FRO Submitted_20220407

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDU14ENTATION POLLUTION CONTROL ACT
No person may initiate a 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 Environment, Health
and Natural Resources. (Please type or print and, if question is not applicable, place VA in the
blank).
Part A.
(. Project Name F 1 ve 0 N4 S C r 0 S s r
2. Location of land -disturbing activity: County E q.Q C 0 �M b
City or Township o M , and Highway/Street 213 R0S+2 �-� i-ee�
3. Approximate date that land -disturbing activity will be commenced: 3 20 a2
4. Purpose of development (residential, commercial, industrial, etc.) ReSi 141 MU AM 1-
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): (50% C I
6. Amount of fee enclosed $ )()0.00
7. Has an erosion and sedimentation plan been tiled? Yes No
Enclosed T
8. Person to contact should sediment control issues arise during land -disturbing activity.
Name Lamct Pay l % G i, Telephone 'l 2 0 - q q 9 2
Landowner(s) of Record (Use blank page to list a dit io al owners):
rI t R cK M v�-� k-ec ro V1 V10 Vf& nC, o V
co. t' y
Name(
(S 0)( 118 0 3$) S. F cn Y_ Gh
Current nailing ddress Current Stre t Address
RoCrcv Mount PC, 27900- PVCKY Moult— NC W901
City State Zip City State Zip
10. Recorded in Deed Book No. 10 7 K Page No. 403
I�
Part B. 105N
1. Person(s) or firm(s) who are fi�PIlly responsible for this land -disturbing
activity (Use a blank sheet to list additional persons or firms :
F,Ve �vif1 C,�o in ,LP �✓ wo do, c-vvCowl
Names)
.560 Olt � �ro11� S t V FlD01' - 5 00 So A Fc t* skft � lb•N floor
Current Mailing Address Current Street Address
Go[vM12V 43L S Co(vr4us 0 N- 419-15
City State Zip City State Zip
y 0os3 c l4)396-0o to
Telephone Telephone

2. (a) If the Financially Responsible Party is not a resident of North Carolina give name and
street address of a North Carolina Agent.
VoNi ,p¢0'-Se (owo�i'ce. r,
16151 LarCo'S'i-ef Ei1a�► ytSue (� 141S) Lalnc2s-�-e� ig 4'O�y, S 8
Current Mailin Address // Current Street Address
C�,arlo e N 2g�77 c:or- Io+k N C 9-8:2- 77
City State Zip City State Zip
(04) 900 - 0702. r-�o LA goo - 0,2-02
Telephone Telephone
(b) if the Financially Responsible Party is a Partnership or other person engaging
business under and 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
Registered Agent.
Name of Registered Agent
Current Mailing Address
City State Zip
Telephone "
Current Street Address
City State Zip
Telephone
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 b y the financially responsible
person if an individual or his attorney -in -fact or if not an individual, an officer. director.
partner or registered agent with authority to execute instruments for the financially
responsible person). 1 agree to provide corrected information should there be any change
in die infonmation provided herein.
- ` ° ( 2e2.1
Date
I' ,7Q ce. C . -v-e�i . A Notary Public of the Count)' of F-r-an�1w,
State o hereby certify that r 7 L06-J.o�
appeared persona y before me this day and being my worn acknowledged that the
above form was executed by him.
Witness my (land and notarial seal, this 30f4' day of &—VLkW00f041;4
fA JOYCE C ALLEY-PLOTT
al Notary Public]
o State of Ohio Notary V U
o My Comm. Expires
ro " ; '? • .' �� March 21, 2025
My commission expire? qL�U