HomeMy WebLinkAboutNCC230244_FRO Submitted_20230127FINANCIAL RESPONSIBILITYIOWNERSHIP 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 Name Tidal Wave Auto Spa "Site & Utility Plan"
2. Location of land -disturbing activity: County Cleveland City or Township Shelby
1000 East Dixon Blvd $ 709 Flmt St 35.2730-81,5278
Highway/Street LatltudeideCirnal deg:eesi Lon gitude(decimal degrees)
3. Approximate date land -disturbing activity will commence: 02/15/2023
4 Purpose of development (residential, commercial, industrial, institutional. etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1 .441 acres
6. Amount of fee enclosed- $ 200 - 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 ❑ Enclosed ❑x No ❑
8- Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Martie Murphy E-mail Address martie@shjconstructiongroup.com
Phone. Office # 706-647-0414 Mobile # 706-975-6682
9- Landowner(s) of Record (attach accompanied page to list additional owners):
TWAS Properties LLC 706-647-0414
Name
Current Mailing Address
City State
10. Deed Book No. 1884
Phone: Office #
115 East Main Street
Current Street Address
Thomastown
Zip City
Page No. 368
706-975-6682
Mobile #
Georgia
State
30286
Zip
Provide a copy of the most current deed.
1000 East Dixon Blvd - GPIN: 2546548002 - D.B. 1390, Pg. 2045
709 Flint St. - GPIN- 2546536980 - D.B. 1461, Pg. 741
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(les).
TWAS Properties, LLC Attn: Martie Murphy
Company Name
115 East Main Street
Current Mailing Address
Thomastown, Georgia 30286
City State Zip
Phone: office # 706-647-0414
ma rtl e@shiconstructiongrou p. Com
E-mail Address
115 East Main Street
Current Street Address
Thomastown, Georgia 30286
City State Zip
Mobile # 706-975-6682
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:
First American Title Ins Co
Name of Registered Agent
223 S. West St., Suite 900
Current Mailing Address
Raleigh, NC 27603
City
State
Phone office # 888-690-7384
Zip
support@liensnc.com
E-mail Address
Current Street Address
City State Zip
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:
CT Corporation
Name of Registered Agent
160 Mine Lake Ct, Suite 200
Current Mailing Address
Raleigh, NC 27615
City State
Phone office # 8$8-724-9870
E-mail Address
Current Street Address
Zip City
Mobile #
Name of individual to Contact (if Registered Agent is a company)
State Zip
(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. if the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Tidal Wave Auto Spa
Company DBA Name
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath. (This form must be signed by the Financially Responsible Person if an individual($)
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.
Marne Murphy
Type or pri name
Signature
Director of Entitlement
Title or Authority
I 43
Date
�,n __----------�----------
" �vr , FO� , a Notary Public of the County of *OVI
State of hereby certify That `Vl� �Ntj appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by himlher.
Witness my hand and notarial seat, this44
day of 20
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