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HomeMy WebLinkAboutNCC221446_Site Plan or Location Map_20220413FINANCIAL RESPONSIBILITY/OWNERSHIP FORM SEDIMENTATION POLLUTION CONTROL ACT No person may initiate any land -disturbing activity on one or more acres as covered by the Soil Erosion and Sedimentation Control Ordinance of the City of Greenville (Title 9, Chapter 8) before this form and an acceptable erosion and sedimentation control plan have been completed and approved by the City of Greenville, Engineering Division. (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. 1. Project Name 2. Location of land -disturbing actIA: County PA City or Township 6tQce-n Vi [ le Highway/Street 4&07 5tMit LA.4 Latitude 35 • W? Longitude• 39oa 3. Approximate date land -disturbing activity will commence: 4. Purpose of development (residential, commercial, industrial, institutional, etc.): esiat eAbot 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): a rM 6. Amount of fee enclosed: $ N . The application fee of $100.00 per acre (rounded to the tenth of acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $900). 7. Has an erosion and sediment control plan been filed? Yes ✓ No Enclosed 8. Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name Of & N w �- E-mail Address OEW WqK YhAA • Cffq-. Telephone - S 1 ti " 1105' Cell #���� ��{� � � 5L5� Fax # 9. Landowner(s) of Record (attach accompanied page to list additional owners): Name Telephone Fax Number I � sa N. GAMM .S{ c _ (757d N- Cuome_ s*w,+ Current Mailing Address Current Street Address ( UCAU AL NL �13 3K Lzia0i 'N- AIL �- 7 B 3`( City State Zip City State Zip 10. Deed Book No. Page No. Provide a copy of the most current deed. Part B. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a comprehensive list of all responsible parties on an ttached sheet): Dewl Ne,`►I.(C. .. --bl� +��,idu e�. yk f • C Name E-mail Address I f SD N. WNA-f Current Mailing Address �Iymiye_ Nc 2�a3'f City State Zip Telephone a57- , 71q- q(()5 4-- 5A -m r Current Street Address City 4-- s n e, State Fax Number A f k ME 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 Add ess WA Wpr Current Mailin6 Address Current Street Address OIN _ A City State Zip CWA State Zip Telephone N Fax Number_ ►y1� _ T (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: _ 0 (A N IA - Name of Registered Agent E-mail AddrresPIA- CuWA- rrent Mailihd Address Current Stre eet Address Wk r LA - City ,, State Zip City hI State Zip Telephone 0f 8- 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 by any change in the information provided herein. Type int name Title or Authority 5 /i A,) � — ature Date 1, 1� e'4o. C. 190 1 Vr , a Notary Public of the County of ,P. � 4 State of North Carolina, hereby certify that 1) c1N( �R Nam \4 k: try _ . _ 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 Z day of t! cr tt % , 20 ZZ - . Notary NETRASEal BOYKIN My commission expires I f - a 4 Notary Public, North Carolina - Pitt County My Commission Expires November 24 2025