NCC224217_FRO Submitted_20221230

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 flan 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, pace NIA in the blank.)
Part A.
1.
K]
4.
Project Name
fake Glenn Dr. Phase 2, Lots 1-7
Location of land -disturbing activity: County Stanly City or Township
Highway/Street
Lake Glenn Dr.
Stanfield
LafitEJde(dedma� degrees)35-21426 Longitude(decimal degrees) -80•4597
Approximate date land -disturbing activity will commence.-
12-20-22
Purpose of development (residential, commercial, industrial, institutional, etc.): Residentaf
Total acreage disturbed or uncovered (including off -site borrow and waste areas). 5.25
E. Amount of fee enclosed: $ 500.00 _ The application fee of $100.00 per acre grounded
wft�
up to the next acre) is assessed without a ceiling amount (Example: 8.1 0-acre application fee is $900).
Checks should be addressed to NCDEQ.
q
9.
His an erosion and sediment control plan been filed? Yes ED Enclosed 0 pia C�
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Steve Helms
Phone: Office#
E-mail Address helm sbuE(d�7a aoi.com
Mobile # [phone]E23
Landowner(s) of Record (attach accompanied page to list additional owners):
Helms Development Properties LLC.
Name
9669 Fred Rd.
Current Mailing Address
Stanfield, NC 28163
City
State Zip
Phone: Office #
Current Street Address
704-634-6623
Mobile #
City State Zip
10. Deed Book No. 1 803 Page No. 1 510 (3)
Provide a copy of the most current died.

Past B.
1. Cornpany(les) who are financially responsihle for the land -disturbing activity (Provide a Comprehensive list
of all responsible parties onaccompanied page.) If the company is a sole proprietorship or if the landowner(s) is
an rndividuaf(s), the name(s) of the owner(s) maybe listed as the financially responsible pariy{res). ;
Helms Development Properties LLC.
Company Name
9669 Fred Rd.
current Mailing Address
Stanfield, NC 28163
City State Zip
Phone: Office #
[e-mail]
E-mail Address
Current Street Address
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 erasion 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 Warne and street address of the Registered Agent:
Helms Development Properties LLC.
Name of Registered Agent
9669 Fred Rd.
Current Mailing Address
Stanfield, NC 28163
City State zip
Phone: Office#-.
helmsbuild@aol-com
E-mail Address
41
Goriest Street Address
city State zip
Mobile # [phone]
Steve Helms md
Name of Individual to Contact cif 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 forth Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent
Current Mailing Address
City State Zip
Phone. Office #
E-mail Address
Current Street Address
City Stake Zip
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. Ifthe 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.
NA
Company DBA Name
The move information is tree and correct to the best of my knowledge and belief and was provided
by me under oath. (This dorm 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 Financlallv Responsible Party). I agree to provide
corrected information should there be any change in the information provided herein.
Title or Authority
116MR
-%J
dY W}77l�����
S
a Notary
public of the County o
■ i
Stake of North Carolina, hereby certify that _—appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him1her.
Witness my hand and notarial seal, this alHoIlay of D62MY_)6Y _ , 20.cqL%le -
Notary U �
My commission expires ry)