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HomeMy WebLinkAboutNCC216032_FRO Submitted_20211029FINANCIAL RESPONSIBILITY/OWNERSHIP FORM SEDIMENTATION POLLUTION CONTROL ACT EXPRESS PERMITTING OPTION 08012007 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. Rockingham Self Storage 1. Project Name g g 2. Location of land -disturbing activity: County Richmond City or Township Rockingham Highway/Street West Green St Latitude 34.940714 Longitude -79.775774 3. Approximate date land -disturbing activity will commence: 9/1 /21 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commerical 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.51 6. Amount of fee enclosed: $ 630 . The Express Permitting application fee is a dual charge. The normal fee of $65.00 per 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). NOTE: Both fees are rounded up to the next whole acre and need to be paid by separate checks to NCDENR. 7. Has an erosion and sediment control plan been filed? Yes No Enclosed X 8. Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name James B. O'Malley E-mail Address jomalley@omalleydevelopment.com Telephone cell # 414-573-0855 Fax # 9. Landowner(s) of Record (attach accompanied page to list additional owners): Rockingham NC Self Storage, LLC 414-573-0855 Name Telephone Fax Number 35 Martin Dr. Same Current Mailing Address Current Street Address Whispering Pines, NC 28327 Same City State Zip City State Zip 10. Deed Book No. 1 893 Page No. 46-47 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. Rockingham NC Self Storage, LLC jomalley@omalleydevelopment.com Name 35 Martin Dr. E-mail Address Same Current Mailing Address Current Street Address Whispering Pines, NC 28327 Same City State Zip City State Zip Telephone 414-573-0855 Fax Number 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: Name Current Mailing Address City State Zip Telephone E-mail Address Current Street Address City State Zip Fax Number (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: Name of Registered Agent Current Mailing Address City State Zip E-mail Address Current Street Address 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: 1_ c Ew61&6f124rV& . PCL4 Engineering Firm or other donsultant Fyttu p FtCEMOVO Individual contact person (type or print) '��► �f � � ittLt'npiKEC� j��Co_r+� , _ E-mail Address qlv _q?,t) - tu3:j Telephone Fax Number 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. James B. O'Malley Member e or print name Title or Authority 7/r� %znza Signat a Date a Notary Public of the County of MC>c>r C_ State of North Carolina, hereby certify that P5 ' Me-L0 appeared personally before me this d2x,,agg,being duly sworn acknowledged that the above form was executed by him. Witness m r` rand n&deal, this VLk day of C�`--` �� , 20 2 Notary L 5'p�yB LAG +A My commission expires IL 2 a -'�O. Count'! ?•�a