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HomeMy WebLinkAboutNCC216526_FRO Submitted_20211208FINANCIAL 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. Williams Grove Phase 2 Lots 20-35 1. Project Name 2. Location of land -disturbing activity: County Nash City or Township Bailey Highway/Street Stoney Hill Church Road Latitude 35.8123580 Longitude-78.0553920 3. Approximate date land -disturbing activity will commence: September 2021 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 8.0 Acres 6. Amount of fee enclosed: $ 2,520.00 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 Alan Mooring E-mail Address alan.mooring@centurycommunities.com Telephone (336) 604-2879 Cell # N/A Fax # N/A 9. Landowner(s) of Record (attach accompanied page to list additional owners): C.T. Williams Corporation (252)205-1151 N/A Name Telephone Fax Number 3303 Sunset Ave, Suite H 3303 Sunset Ave, Suite H Current Mailing Address Rocky Mount City 10. Deed Book No. 3032 Current Street Address NC 27804 Rocky Mount NC 27804 State Zip City Page No. 844 State 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. WJH LLC Name dave.hodgman@centurycommunities.com E-mail Address 3091 Governors Lake Drive, Suite 300 3091 Governors Lake Drive, Suite 300 Current Mailing Address Norcross GA City Current Street Address 30071 Norcross GA State Zip City State 30071 ME Telephone (833) 791-0192 Fax Number N/A 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: Dave Hodgman dave.hodgman@centurycommunities.com Name E-mail Address 1225 Eastchester Dr #107 1225 Eastchester Dr #107 Current Mailing Address Current Street Address High Point NC 27265 High Point NC 27265 City State Zip City State Zip Telephone (336) 362-6211 Fax Number NIA (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: NIA NIA Name of Registered Agent E-mail Address NIA NIA Current Mailing Address Current Street Address NIA NIA City State Zip City State Zip Telephone N/A Fax Number NIA (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: Ballentine Associates, PA dillons@bapa.eng.pro Engineering Firm or other consultant E-mail Address Dillon W. Smith, PE (919) 929-0481 Ext. 111 (919) 489-2803 Individual contact person (type or print) 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. Dave Hodgman Type or print na Regional President -Mid Atlantic Region Title or Authority a-17-Z,'I Date aL ea ID 1 Z , a Notary Public of the County of i State of North Carolina, hereby certify that _ -4 j j f_ .O,O appeared personally before me this day and being duly sworn acknowTecTd&d that the abo a form was executed by him. Witness my hand and notarial seal, this ��day of 20 Tara Rabitz Notary t RY PUBLIC Wake County My commission expires North Carolina My Commission Expires November 9, 2i125