HomeMy WebLinkAboutNCC230033_FRO Submitted_20230111FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
Nn person n ay initiate snv land-disturbillu a(.-J-1v'1t-v on one or more acres as covered by the. Act before this
form and an acceptaeblerasion ao sedimentation control flan have bHen completed and approved by the
Land Quality(-')PCtinn.h N.G. �cpartniE;nt of Environmcmt and Natural Resources. (Please type or Print and, if
the question is not or the e-mail and/or fax information unavailable, place N/A in the blank.)
Part A.
1. Project NameB'11111et's FRun -Lot 3- ---------
2. Location of land -disturbing activity: County Chatham. City or Township.,_., Moncure
Highway/Stroc)t �j'� l3ill�ts Rur latitude 35-6273 _ _ _ ._. Longitude -79-0605... .._ _.,._
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3. Approximate date land -disturbing a ctivity will commencet _ _2/1/2023
4. Purpose of development (residential, commercial, industrial, institutional, et(..):_. _ residential _ ^_
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):__ 1.44
Fi. Arnount of fee, enclosed: $. 130 .. The. application fee of $6.5.00 per acre (rounded
up to the.. next acre) is assessed without a ceiling amount (Exampl): a 9-acre: applicatioti fee is $585)r
Y. Has an erosion and sediment control plan been filed? Yes _ .__.X _ _ No__—_._.___..
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
_11, E-mail
N,a- me y1pp Address
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9. Landowner(s) of Record (attach accornpanIc�d page to list additional owners):
Lifen VVu & H Ze a o Q I U 919886'0473 n qWpE0*p_ W . 1 0 j 1 0 1 Ld -le 11FNv"EE4qL- WWI 0 11%0
Name Telephone Fax Nurn'ber
b. __ _ _ _ 1040 Austin P.orid Dr __ _ 1040 Austin Fond D . r
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Current Meiling Address Current Streo-it Addrc-,)ssN
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Cary NC 27519, _. Gary. Y513.__.___.
City State zip City State Lip
10. L�'e�ed F3ook No. 02304 i'agc� No,_�._, Q�Q4 _ f'rc�vdH a copy of the alost current deed.
Part B.
1. rerson(cs,) firrns) who are; financiorally re...(..)%ponsible for the., land,disturbing activity (Provide a
comprehensive 1-1st of all responsible particNrs an an attached sheet):
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by me under oath (This farm mast be signE;cl hj the FinanciallyRe..soonsiblePerson if an indiviouai
or his attorney -in -fact, or if not an individual, officer, director, partner, or registered agent with
ti-,A aiithr�rity ton execute instruments for the-, Financially Responsible Person). I agree t� provide
in the infarmation provided he -rein.
corrected information should there,. be any Change F. P .................. V.,
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s not a resident of North Carolina, give name and street address
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The above information is true and correct to the. best of my kn-owledgcdl. and belief and was provided
ANDYA
ry lic
Wake Co., North Carolina
My Commission Expires August 14, 2027
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by an
this I.. _..__._day o
appeared
ged that the above form was
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Notary
My commission cXpires'I27