NCC221603_FRO Submitted_20220426

FINANCIAL RESPONSIBILITYIOWNERSHIP 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. GC Lot 692 Carteret
1. Project Name
orTownshi
2. Location of land -disturbing activity: Chatham City Y P Williams
Highway/Street 96211 Carteret Latitude 35.8438 Longitude-79.0402
3. Approximate date land -disturbing activity will commence: 04/26/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 0.18
6. Amount of fee enclosed: $65.00 . 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 Bled? Yes X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name JoSif Skela E-mail Address [e-mail]
Telephone Cell # 919.537.1491 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
GA 240 LLC 919.656.3242 NIA
Name
480 Sun Forest Way
Current Mailing Address
Telephone Fax Number
480 Sun Forest Way
Current Street Address
Chapel Hill NC 27517 Chapel Hill NC 27517
City State Zip City State Zip
10. Deed Book No
2138
Page No. 0673 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 solo proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Skela Homes LLCIJosif Skela [e-mail]
Name
1006 Clarence Drive
Current Mailing Address
Chapel Hill NC 27517
City
State Zip
Telephone [phone]
E-mail Address
1006 Clarence Drive
Current Street Address
Chapel Hill NC 27517
City
Fax Number N/A
State
3N
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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 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:
Anila Hito
Name of Registered Agent
1006 Clarence Drive
Current Mailing Address
Chapel Hill NC 27517
City
State Zip
Telephone [phone]
[e-mail]
E-mail Address
Current Street Address
City State Zip
Fax Number NSA
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.
Josif Skela
Type
re
General Manager
Title or Authority
4/21 /2022
Date
a Notary Public of the County of
State of North Carolina, hereby certify that 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 day of APLI-L-
20
hLLEN
S. LEFKOWITZ Notary
Se I NOTARY PUBLIC
Wake County My commission expires
Norm Carolina
Mrn
Y Comission Expires Nov, 17, 20251
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