NCC222767_FRO Submitted_20220818

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 address or phone
number is unavailable, place NIA in the blank.)
Part A.
1. Project NameBrights Creek - Lot2056
2. Location of land -disturbing activity: County Pot h City or Township M l l l Spring
Highway/Street Latltude(decimal degrees) Longltllde(decimai degrees)
Stafford L,n N. 36.33298-82.28112
3. Approximate date land -disturbing activity will commence: J u ly 20, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1 Acre
6. Amount of fee enclosed: $1 00 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example. 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes 0 Enclosed ❑ No 0
0
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameMatthew Padula E-mail Address [e-mail]
Phone: Office # 864.401.2355 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Larry Holder �„�sp ��5 303-881-1799
Name Phone: Office #
PO Box 2849 Stafford Lane N.
Current Mailing Address Current Street Address
Winter Park, CO 80482 Mill Spring, NC
City �I State Zip G City
10. Deed Book No.468 Page No.600
State
303-881-1799
Mobile #
28756
Zip
Provide a copy of the most current deed.
IVED
LAND UUM0 I y
ASHEVI LLE

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) if the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Highland Design & Construction
Company Name
214 Red Barn Road
[e-mail]
E-mail Address
214 Red Barn Road
Current Mailing Address Current Street Address
Landrum, SC 29356 Landrum, SC 29356
City State Zip
Phone: office # 864.401.2355
City State Zip
Mobile # [phone]
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Highland Design & Construction
Name of Registered Agent
214 Red Barn Road
Current Mailing Address
Landrum, SC 29356
City
State Zip
matt [e-mail]
E-mail Address
214 Red Barn Road
Current Street Address
Landrum, SC 29356
City State Zip
Phone: Office # 864-401-2355 Mobile # n'a
Matthew Roy Padula
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent
Current Mailing Address
City State
Phone: Office #
E-mail Address
Current Street Address
Zip City
State Zip
Mobile # RED
Name of Individual to Contact (if Registered Agent is a company)
IANO QUALITY SECTION
ASHEVILLE.

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
nla
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Matthew Padula
President
Type or print name Title or Authority
718122
Sign tune Date
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I, �'�)YUV�( A, Qt n VkXV , a Notary Public of the County of
State of North Carolina, hereby certify that M U(aL�Q. appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this S.!day of
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RECEIVED
LAND QUALITY SECTION
ASHEVILLE