NCC232446_FRO Submitted_20230821

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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.)
Part A.
1. Project Name cllOv n fit (,S 50L l
2. Location of land-disturbing activity:County u�CL 'L City or Township J ---0
Highway/Street 0Yll CLr `ZC\ Latitude 35, 4,76g Longitude 7 . f .35 3
3. Approximate date land-disturbing activity will commence: O-"/S
4. Purpose of development(residential, commercial, industrial,institutional,etc.): I?�S i r evL-f-fc,I
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): (e. �?
6. Amount of fee enclosed: $ .57 . The Express Permitting application fee is a dual
charge. The normal fee of$65.00 per acre(rounded up to the next acre)is assessed without a ceiling
amount. In addition, the Express Permitting supplement is $250.00 per acre up to eight acres, after
which the Express Permitting supplemental fee is a fixed$2,000.00 (Example:9 acres total is$2,585).
7. Has an erosion and sediment control plan been filed? Yes v0. No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Belay\ E-mail Address 5c�5 COV IA& `l•L�`�1`
Telephone C(J¶(-Lf -)7 3Q Cell# SC(/Yte Fax# e/C/ -
9. Landowner(s)of Record(attach accompanied page to list additional owners):
51 3 1 °lurck t e ; (9-62 IZ -�8 �
Name Telephone Fax Number
OD PA3.)( 'PDC') L' (e-) q ry,F, 5-free+-
Current Mailing Address Current Street Address
COr (
�tk— 75 (a- gnie j5 h L� g76 r 7
City State Zip ff City State Zip
10. Deed Book No.19 3�> Page No. L`'2'(( Provide a copy of the most current deed.
Part B.
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.
�l�l Cht)rrt, 12tk E ' 11 �C3-ti t oc,1 y ((jr- , u4,,t
Name E-mail Address
Poet), 1866, (n 4 6- ne r 5-f reef-
Current Mailing Address Current Street Address
C erg a_r 76(z_ J(� ►1 C �7C�(�
City State Zip ity State Zip
_.. mow.,..

Telephone % -(o1L.^6455 Fax Numty 1 t ` 53(4-)3(a DA_--
2 (a)If the Financially Rtisponseble Party is not a it•.ed'nt of Nee..• name and street:address
of the designated North Caretina Agent
Name L-mad Addles%
— —
Current Mailing Address Cerrrrit Street Adrirrs.
City— — State Zip C�tv --— Stair. Zip
Fax Number - - --
Telephone — — — —
(b) II the Financially Respect:Able Party is a Partnership or other person engaging■t bus`ne`'s under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Frnanually Responsible
Party is a Corporation,give name and street address of the Registered Agent
E-mail Address
Name of Regstcrcd Agent
Current Mailing Address Current Street Address
City State zip City State Zip
Telephone Fax Number - --
(c) In order to facilitate Express Permitting• it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation
Engineering Firm or other consultant
E-mail Address
riot
Individual contact person(type or P ) Telephone Fax Number
and
aThend abovea form is true and cormthe F nancially Responsible Pct to the best of my erson if an,ndnrid al or his attorney-in-
fact.under oath(This form must be signed by
or if not an individual, by an officer, director, partner,or registered agent with the authority to execute
instruments for Vie Financially Responsible Person). I agree to provide corrected information should there be
any change in the information provided herein.
- uCD AAalalelq �.t Mentb_e_f‹.
Title or AilIN-W,
Type n e l
Uar•
Stgnatu \}_
_
I n I ('Hk/2CS ,a Notary Public of the:County of Wry ` " s-A
State of North Carolina,hereby certify that
SreVe" 4 r'l I e'o L y appeared persona
before me this day and being duty sworn acknowledged that limo aterve form was •,.•,-t�'d by him.
Witness my hand and notarial seal,this ? day of—_ -_Vs%1S 1T 20 ,
` • Notary (� (�
f r JOHN TRAVERS ! D -L + dd C
r.) r trStiiort oxpros`--
NOFARY PUBLIC
WATAUGA COUNTY
NORTH CAROLINA
_ I.