NCC232234_FRO Submitted_20230727

Pitt County
74 �'wa Planning Department
Development Services Building
. 1717 W. 5th Street
�� Greenville, North Carolina 77$34-1696 James F.Rhodes,AICP
Telephone: [phone] Director
Fax: [phone]
Financial Responsibility /Ownership Form
Soil Erosion and Sedimentation Control Ordinance
No person may initiate any land-disturbing activity on one or more contiguous acres as
covered by the Act before this form and an acceptable erosion and sedimentation control plan
have been completed and approved by the Pitt County Planning Department. (Please type or
print and, if question is not applicable, place N/A in the blank.)
Part A.
Project Name_ DC&C Shop and Office Building
2. Location of land-disturbing activity: County PITT
City or Township Pitt County , and Highway/Street US HWY 264
3. Approximate date land-disturbing activity will be commenced: July 2023
4. Purpose of development (residential, commercial, industrial, etc.):_ industrial
5. Approximate acreage of land to be disturbed or uncovered: 1.98
6. Has an erosion and sedimentation control plan been filed? Yes x_ No__.__ Attached
7. Person to contact should sedimentation control issues arise during land-disturbing_activity:
Name Brian O'Kane Telephone [phone]
8. Landowner(s) of Record (Use blank page to list additional owners):
Design Construction and Commissioning, Inc. N/A
Name(s) Name(s)
3406 Star Hill Farm Road N/A
Current mailing address Street address
Greenville NC 27834 N/A N/A N/A
City State Zip City State Zip
9. Recorded in Deed Book No. 4351 Page No. 485
Part B.
I. Person(s) or firm(s) who are financially responsible for this land-disturbing activity (Use
the blank page to list additional persons or firms):
Design Construction and Commissioning,Inc. Prem.Singla
Name of person(s)or Firm(s) Name(s)
3406 Star Hill Farm Road _ 3406 Star Hill Farm Road
Current mailing address Street Address
Greenville NC 27834 Greenville NC 27834
CityState Zip City State Zip
919-271-9297 _919-271-9297
Telephone Telephone

2. (a) If the Financially Responsible Party is a Corporation, give name and street address of
the Registered Agent.
N/A N/A
Name(s)
N/A N/A
Current mailing address Street Address
N/A N/A N/A N/A N/A N/A
City State Zip City N/A State Zip
N/A
Telephone Telephone
(b) If the Financially Responsible Party is a Partnership give the name and street address
of each General Partner (Use blank page to list additional partners):
N/A, ------ — -- N/A -- — ---
Name(s) Name(s)
N/A — N/A _
Current mailing address Current mailing address
_N/A N/A N/A N/A N/A N/A —_
City State Zip City State Zip
N/A N/A
Telephone Telephone
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/her attorney-in-fact or if not an individual by an officer, director, partner, or
registered agent with 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.
Prem Singla President
Type or print name Title or Authority
7f-''77 a z3
Signature Date
f, , Carbe* ,
a Notar 7 Public of the County of P4--/. State
of Nort 1 Carolina, hereby certify that ree.--1 i. 1o.--
appeared personally before me this day and being duly sworn ackkwledged that the above form
was executed by him. D'_ ] 2,
0„,,,,,,,,i,,",,,,,� Witness my hand and notarial seal this 5__day of G .—.—.. 20,2
,,,,,` CORg
�p o� .0 AR 6�,. - Notary
o (1JMy commission expires_AR filo/
pUBV� �ry,�UO
�'',/, / coi 1� ee,%e'a