NCC221414_FRO Submitted_20220411

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 Environment and Natural Resources. (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.
1. Project Name 3819 Tuckaseegee Townhomes
2. Location of land -disturbing activity: County Mecklenburg City or Township Charlotte
Highway/Street3819 Tuckaseegee Road Latitude 37.249 Longitude-84.495
3. Approximate date land -disturbing activity will commence: 4/18/22
4. Purpose of development (residential, commercial, industrial, institutional, etc): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.1
6. Amount of fee enclosed: $ 130.00 . 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).
7. Has an erosion and sediment control plan been filed? Yes x No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Justin Roath E-mail Address iustinakearevconstruction.com
Telephone
980-444-6510 Cell # 704-450-2003 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Rama Yada
Name
8021 Wicklow Hall Dr
Current Mailing Address
704-287-6252
Telephone
Current Street Address
Matthews NC 28104 _
City State Zip City
State
Fax Number
10. Deed Book No. B36152 Page No. 299 Provide a copy of the most current deed.
Part B.
Zip
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
I_\9 11RM. •C7i3M4to
Name
8021 Wicklow Hall Dr.
Current Mailing Address
Matthews NC 28104
City State Zip
Telephone [phone]
ramayadaa-gmail.com
E-mail Address
Current Street Address
City State Zip
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
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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.
Rama Yada
Type or print name
Signature
Managing Member
Title or Authority
3/30/2022
Date
I, Cynthia Vincent , a Notary Public of the County of Iredell
State of North Carolina, hereby certify that Justin Roath 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 30t"
day of March
Notary
20 22
My commission expires 4/1/2022