HomeMy WebLinkAboutNCC221301_FRO Submitted_20220406FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
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 Environment and Natural Resources. (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.
1. Project Name Saner Springs Subdivision - Phases 3A, 3B, 4C, 5and 6
2. Location of land -disturbing activity: County Moore -City or Township Aberdeen
Highway/Street Sandy Spdngs Road Latitude _ 35.1159170 N Longitude_ 79.407485° W
3. Approximate date land -disturbing activity will commence: September2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 62.4 AC
6. Amount of fee enclosed: $. 4095 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
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 Michael Kaney - MIKA Management E-mail Address michaelk@mikamgmtsolns.com
Telephone 919-917-7298 Cell # 919.610.2583 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
See attached_
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City State
Zip
10. Deed Book No. 5570 Page No._35 & 38 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
McKee Homes LLC bdipasquaie@mckeehomesnc.com _
Name E-mail Address
109 May Street Suite 301 109 Hay Street Suite 301
Current Mailing Address Current Street Address
Fayetteville _NC _ _ 28301 -Fayetteville NC 28301
City State Zip City State Zip
Telephone 919-909-9632 Fax Number.
Property Owner Information:
MCKEE HohmEs
a Delaware limited liability company
Grantee's Address;
109 Ray Street, Suite 301
Fay ettev ille, NC 28301
NC EvERGREE r DEVELOPMENT LLB',
a Texas limit:d 1iabilit}' company
Cirantee-s Address'
4334 Swarthmem Street
Houston_ TX 77004
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
Telephone
E-mail Address
Current Street Address
Zip City
Fax Number
State Zip
(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
Telephone
E-mail Address
Current Street Address
Zip City State Zip
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.
Patrick J. McKee - McKee Homes, LLC Member
Typgrar'grint name
Signature
-------------
Title or Authority
Date's
a Notary Public of the County of ) rr6 k itCcrei
State of North Carolina, hereby certify that appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this 1, Tv day of , 20 �24
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