HomeMy WebLinkAboutNCC220675_FRO Submitted_20220211NC Department of
FINANCIAL RESPONSIBILITYIOWNERSHIP FORM Environmental Quality
SEDIMENTATION POLLUTION CONTROL ACT 1�eceived
EXPRESS PERMITTING O
PTION 1-1�92021
7 7 ?
No person may initiate any land -disturbing activity on one or more acres as covered by thg; 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 completedJorm:to there
appropriate Regional Office. (Please type or print and, if the question is not applicable or the e-mail and/or
fax information unavailable, place NIA in the blank.)
Part A. Calebs Creek (MU-1)
1. Project Name
2
3.
4
Location of land -disturbing activity: County Forsyth City or TownshipKernersville
Highway/Street Ogden School Rd Latitude 36.06441 Longitude-80.08974
Approximate date land -disturbing activity will commence: 01 /24/2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
10.7
G. Amount of fee enclosed: $ 3100 The Express Permitting application fee is a dual charge.
The normal fee of $100,00 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 $2,900). NOTE: Both
fees are rounded up to the next whole acre and need to be paid by separate checks to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Debbie Joyce E-mail Address debbieJoyce@green-louis.com
Telephone 336-378-1778 Cell # 336-669-8189 Fax # 336-230-1821
9. Landowner(s) of Record (attach accompanied page to list additional owners):
BOMA North Carolina, LLC
Name Telephone Fax Number
836 Good Hope Drive
Current Mailing Address Current Street Address
Castle Rock, CO 80108
City State Zip City State Zip
10. Deed Book No. 3274 Page No. 808 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.
BOMA North Carolina LLC
Name E-mail Address
836 Good Hope Drive
Current Mailing Address
Castle Rock, CO 80108
City
Current Street Address
State Zip City
Telephone 307-699-4749
Fax Number
State
Zip
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:
Debbie Joyce debbie.joyce@greer-louis.com
Name E-mail Address
1110-A Dover Road 1110-A Dover Road
Current Mailing Address Current Street Address
Greensboro, NC 27408 Greensboro, NC 27408
City State Zip City State Zip
Telephone 336-378-1778 Fax Number 336-230-1821
(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 E-mail Address
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:
SEH of North Carolina, PLLC timdieke@sehinc.com
Engineering Firm or other consultant E-mail Address
Trent Imdieke 320-309-7497
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). 1 agree to provide corrected information should there be
any change in the information provided herein,
Kory Reimann Manager
Type or pr' r A me Title r Authority
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Si ature Da
I, a Notary Public of the County of ( u i
State of North Carolina, hereby certify that J<ot s � Yolr� appeared personally
before me this day -and being duly sworn acknowledged that the above form was executed by him.
Witness my ha S *;.1al seal, this ~ - day of � Mj 20
TARP U My commission expires 3
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