NCC223165_FRO Submitted_20220909

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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.
Project Name Ariston Place
2. Location of land -disturbing activity: County Davie City or Township Bermuda Run
Highway/Street HM801 Latitude(decimal degrees) 36.004447 Long itude(decimaldegrees) -80.438131
3. Approximate date land -disturbing activity will commence: September 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.5416
6. Amount of fee enclosed $2,450 . The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition, the Express Permitting supplement is $250 per acre up to eight acres, after which the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900). Checks
should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ® No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name: Sateesh Reddy
E-mail Address: [e-mail]
Phone: Office #
Mobile# [phone]
9. Landowner(s) of Record (attach
accompanied page to list additional owners):
Ariston Place LLC
330.762.9102
Name
Phone: Office # Mobile #
19 N. High Street,
19 N. High Street
Current Mailing Address
Current Street Address
Akron. Ohio 44308
Akron Ohio 44308
_
City State
Zip
City State Zip
10. Deed Book No. 1224
Page No.
296 Provide a copy of the most current deed.
Deed Book No. 1224
Page No.
304
Deed Book No. 1224
Page No.
309
Deed Book No. 1224
Page No.
315
Deed Book No. 1224
Page No.
447
Deed Book No. 1224
Page No.
451
Deed Book No. 1224
Page No.
456

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).
Ariston Place LLC
Company Name
19 N High Street
Current Mailing Address
Akron, OH 44308
City State Zip
Phone: Office #330.762.9102
sreddy ,signetre.com
E-mail Address
19 N High Street _
Current Street Address
Akron OH 44308
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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office #
Mobile #
Name of Individual to Contact (if Registered Agent is a company)

(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 Parry 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.
Company DBA Name
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
MLA Design Group
Engineering firm or other consultant
Paul Fidishun
Individual contact person (type or print)
paul(o-)-millerla.com
E-mail Address
336-765-1923
Phone: Office # Mobile #
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.
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Type or print name
Signat re
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Title or Authority
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Date
I, �_� et�n�Cz r Nth ilk , a Notary Public of the County of _Dutllac
State of Florida, hereby certify that ';penC,(C �A�cO+ _ 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 20
rin 41A 4wau_�'
N to ry
Seal My commission expires «1 � I i
� rcr�, Notary Public State of Flad"
f YIN Jennifer Nealis
i My commisslon
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