NCC222766_FRO Submitted_20220818

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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. ProjectNameBright's Creek - Lot 2082
2. Location of land -disturbing activity: County Polk City or Township Mill Spring
Old Gold Mine Way 35.33599-82.28721
Highway/Street LatltUde(decimaf degrees) LongltUde(decimai degrees)
3. Approximate date land -disturbing activity will commence:July 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 L. 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 M Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name -Matthew
G Padula E-mail [e-mail]
Phone: Office # 864.401.2355 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Paul M. Mack and wife Patricia V. Mack n/a 561.239.9913
Name
1505 Addison Ave.
Current Mailing Address
Boca Raton, FL 33486
Phone: Office # Mobile #
1505 Addison Ave.
Current Street Address
Boca Raton, FL 33486
City State Zip G City
10. Deed Book No.459 Page No.670
State
Zip
Provide a copy of the most current deed.
RECEIVED
Jul, I. i Z027
LAND QUALITY SECTION
ASHF11111F

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 [e-mail]
Company Name E-mail Address
214 Red Barn Road 214 Red Barn Road
Current Mailing Address
Landrum, SC 29356
Current Street Address
Landrum, SC 29356
City State Zip City State Zip
Phone: Office # 864.401.2355 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
[e-mail]
E-mail Address
214 Red Barn Road
Current Street Address
Landrum, SC 29356
City
Phone: Office # 864 401-2355 Mobile # nla
Matthew Roy Padula
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(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
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip
RECEIVED
LONE) QUALITY SECTION
AS,faFVl1 I

(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
Ty e or pri dame Title or Authority
4/28/22
Si nature Date
a Notary Public of the County of 1C d L
State of Notch Carolina, hereby certify that appeared 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 day of
olIIIII II r11111
0* NOte Pubfic
Polk �q
My com my
yp0�' 14-2026 A
y LAIR
My commission expi
RECEIVED
LAND QUALITY SECTION
ASHEVILLE