NCC230397_FRO Submitted_20230214

FINANCIAL RESPOHSIBU fl Y/OTONERSHIP FORM
SEDIMENTATION POLLUTION N 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 and/or fax information
unavailable, place N/A in the blank.)
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Project Name DORSEfF 51-REEF FOWIVROMES
Location of land -disturbing activity:
County SFRAILY
City or Township
AIM
Highway/Street DORSEFF S F -
Latitude 35°2239
Longitude
-6'0.3227
Approximate date land -disturbing activity will commence: 1146® 2. 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): RESIDFAIFIRI,
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 7.05
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).
Has an erosion and sediment control plan been filed? Yes A No Enclosed
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name JRMIE MOORE E-mail Address Jamielnoores6radingO cloud°com
Telephone (704r) 547-577 2 Cell #
i` liq Fax # A116
Landowner(s) of Record (attach accompanied page to list additional owners):
I-fqg Proper-bies LIL-C 701 79q-3900 A11A
Name Telephone Fax Number
226 S- C081-C AVE-
Current Mailing Address
City
State Zip
10. Deed Book No. 772 Page No
Pan B.
226 5° C061,E 6 VE°
Current Street Address
06I<80RO /VC °
City
State
Zip
Provide a copy of the most current deed.
1. Company (ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole
proprietorship the name of the owner or manager may be listed as the financially responsible party.
FRS Propert7ies, L1,C paustin @OlympicCons &ruc�,-ioninc-corn
Name E-mail Address
22S 5° 6081-E 6VE° 22S 5° COBLE FIVE°
Current Mailing Address Current Street Address
0,g980R0 PVC 2&729 06980RO 1AVIC 2&729
City State Zip City State Zip

Telephone (704) 79q-3906 Fax Number A09
2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address of
the designated North Carolina Agent:
f1J/q
Name E-mail Address
A09 AIM
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone A09 Fax Number Ai/19
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible Party
is a Corporation, give name and street address of the Registered Agent:
,.'014AI iEAl. John T-eal23@Yahoo-com
Name of Registered Agent E-mail Address
12600 P00- KRY DRIVE
Current Mailing Address
/nol-RAID /VC 2&707
City
State Zip
72600 MOLT XRY DRIVE
Current Street Address
01-19AID A/C 26707
City State Zip
Telephone �70Lf) 6 a7-7520 Fax Number A09
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 Person). I agree to provide
corrected information should there be any change in the information provided herein.
JOP/V W. 'FFAiL 1X67M8FR
Type me Title or Authority
Si tur Date
1, %�1 a Notary Public of the County of
State of North Carolina, hereby certify that _A4gj_
appeared
personally before me this day and being duly s rn acknowledged that the above form was executed
by him.
Witness my hand and, notarial seal, this day of 20
e
.aI - Notary C� JI i� tom,. �%O ie_�
i
My commission expires l (o _-2 'n -:2 S