NCC240144_FRO Submitted_20240117

Soil Erosion and sedimentation Control
l e t .t I t . .% C
Financial ResponsihilitvOwnership Form
\UT REQURF.I) TO BE C:O.t1PLE TED FOR RFSII't.\TL4L LOT PER t11TS.
PLEASE READ Till 101.I OWING INFORMATION:
MEN sector must be issued:n the:reserve of;Noun
2, I his form must be slimed by the;arc Item owner•i ar. rn;t.;swua:.It owned bs a.ompar s or itxputat:ur:•this form most he signed b}an officer.
Cue•tax.pan:cr aftornes-,r.-fact.or.xhes person with authonrs to csc vte,ratrsmerts for the isxporat:on and accompam:e t by a cornpictc i:•t of al.
partners,managing members and registered agens of the collapses or cnrponixm
3 t Thu form must also be s:into:by the anttal':y respnns:Sle parry and\C agent if app..ca7 et Same pros-Alms of o=ab.-tve app`t
4) If the iandesnet and fiara,.a_ly resp,,ns blc part are different_the completer and c:gr.:rg of this ptsge sJtail sen a as documerraror
a:Lncslc'dgmg the IatpiowTler consents to and nut tnces the f:narc.:aiiy rc pons;'+'e pat t.,undertake to"r:rh,:i! ar;-d sr}rbing as-Its-it}on the
land.,ssners rams)et'a ..;enuf.e.'or:h.is apP:'.at;.•r
4 r Pt: or. :•rr. or.. ..rrc.t t. t:,.ast of ms lr..••••• c ac.i ,., r:..: n.,;...:..ic,+ . n,. ah;,c lantk7 oath
\.i I.i,i-f).:utt::ni; per,r.tt, are .at c •.•t yr.sn 'r•.m the date of:nuance It,r:umstarAes Marrant,the aroma may se eatenjed far
2, sears re: the :r,rC,t.•n. ,.t ;)x l'.a)atn (•u:rr. S.,:: Fr...:,,r, .ram+ Sedmsenratian C.xttru: Ordinance l ptx:written notice. the Land-thdurhirg
:.cnr:t may nr ret.,►ae t.r rr.lare watt• the ( cC,nar.: It the permit :s rescAcet:, a(! other
permtts sr,;,' apy+tusau arc withheld until
the prnp.m ; eyes agar. .r. ;.rt; ..a".rc a th C hart,3rr, ( .•any, rega!at.•r.. :mtrr.;otter nonce.a civil Pena is(fine)car Se,nstigased
tga,n.t the sro perts nurc'and or a.:e.roral than:a ': resecr..?,.c party of ar:,for lie ar:If s of the Chatham Count'. Sod Frosion and
SeJ:rnerlst:.x(.intro!l h'^.anc ' -pins'^. , s^'. S *r rr.ncr r,...at;o,r scr,tat sr:: •assessed 3:', for ct d.ati••hc pr;,. rt. i.:c s:e'.al-or
"_...:...r:^ •., ..,. arZ" r[.:r >ae: -..:1: rC._ . .-a•.. ? .i:r :'. w,t(F',iiu•a rer r..t..e. .
ON\ER OF PROPERTI :
Name aril l'tie. Tana & Igra Imam
C•>mt>an� .r tpplicab.c
Signature -1 -1 �,�— - r :
FI\.1\CIAI.I.1 RESPONSIBLE P. RT1' (applicable unl, if different from property owner):
\ame and rifle- J r arnpomtzz. Presroer:
ompan. Empir Cc actor Inc
Signature
NORTH C.-1ROLI . AGENT (if any):
\ante anc . . ..
( ontpun. --
xrclKlFaFit1F1K>K#1fltrxlF***#xx*Pe*ltc*:kx7z>Krltaell ****tkxattktktflkyt>it>tenl)skieir****tk**********
rki 4 a -Ars-i,c 4-4,,;.) . a Notary Public of LLD County to the seat
c►I— — t C' - (Xi hereby certify that i. C f1�'1ah. �r
�rl , .1 ,.t slt f ^^an-
appeared before me this day and under oath acknowledged reading the information abos a and acknowledged that the
above form was executed by him or her. +}�
Witness in hand and official seal.this the5 Jay of k�.� .
•
1•
Notary Punk;
My commission expires v4 'I Li f ac.J, an y (SF \t,+ Z
Page 3 of 3