NCC233043_FRO Submitted_20231011

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered by the Soil Erosion and
Sedimentation Control Ordinance of the City of Greenville(Title 9,Chapter 8)before this form and an acceptable
erosion and sedimentation control plan have been completed and approved by the City of Greenville,
Engineering Department. (Please type or print and, if the question is not applicable or the e-mail address or
phone number is unavailable, place N/A in the blank.)
Part A.1. Project Name Q 1114 Viot Ge rl'
2. Location of land-disturbing activity: County PI P City or Township W iCPv;I le,
Highway/Street VO4% r"tr-1" /3r, Latitude(decmal degrees)/3 c�m ongitUde(deaI degrees)77,3 V138
3. Approximate date land-disturbing activity will commence: (Ail O be of 0
4. Purpose of development(residential,commercial,industrial,institutional,etc.): POO 1
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): • d 3 _ _
6. Amount of fee enclosed:$ . The application fee of$100.00 per acre or portion
thereof (rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre
application fee is$900).
7. Has an erosion and sediment control plan been filed? Yes 0 Enclosed ❑ No 0
8. Person to contact should erosionand sediment control issues arisen during land-disturbing activity:
Name SQM*e hQA9 E-mail Address Pcliopert •OhIM 4014;I.COrl
Phone: Office# ?S 344-110) Mobile# )Sj"'1t6' 4S7� J
9. Landowner(s)of Record(attach accompanied page to list additional owners):
MCI 4 Mq Polktr JS.7-M-620
Name Phone: Office# Mobile#
(1y4 01%. Qq i Van G-er-) Orb.
Current Mailing Address Current Street Address Wiht't±rV;)4 N.e, Q85°10 U))niet ih , CC. g5c1 [)
City • State Zip City
State Zip
10. Deed Book No. 3 S4 p Page No. 6 I v Provide a copy of the most current deed.

•
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(ies).
Oc'
1 Lc 144r0lI1.eaj,RS+it()A Le Pc th'opedeAM 63 mat I, OM
Company Name E-mail Address
O ►C% ) i e a Rot 3alg x,t1re1) (foil.
Current Mailing Address Current Street Address
Grlenwah kle •)-1,S S 8 Geeeavo le 1 t SS
City State[ Zip City State Zip
Phone: Office# JS 1 1 -36-7 -)'Q) Mobile# �J - 9 16' (57.S
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:
�Gr, 1 t t Lc"5 1.11- 6-Wot! etc, cjm S9m I, �'DAr
Name of Registered Agent E-mail Address
I3S 5 , 0P. ) S ,SL,oIO fJ e•
Current Mailing Addre Current Street Address
tv;1 ie I N . Jff59 0 \\f:Aferv;I l e Sg(�
City State ,1 Zip City State ZipZip
Phone: Office# DP- 36 Y _ �� Mobile# (p S.�[ -gI)b- 6S?S'
Tarn e LDoi
Name of Individual to ContactORegistered 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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Name of Individual to Contact(if Registered Agent is a company)

(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.
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(s)
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.
3C4A,it Lc.s ,O- Pft3, OW61 c/'
Type or pri ame Title or Autho ity
10-s- a,7
Si natur Date
I, b! ,c70 0- , a Notary Public of the County of P.
I r
State of North Carolina, hereby certify that �u..�.�t G � appeared personally
before me this day and being duly sworn acknowledged that the ab a form was executed by him/her.
Witness my hand and notarial seal, this .5- day of C(.-- l f Le-- , 20c)-
Notary—'9L<a°
My commission expires