HomeMy WebLinkAboutNCC221746_FRO Submitted_20220512FINANCIAL 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 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 address
or phone number is unavailable, place NIA in the blank.)
Part A.
1. Project Name Anderson Creek Crossin_q, Phase 8 Section 4 - Lots 44 52 & 53
2. Location of land -disturbing activity County Harnett City or Township_ Anderson Creek Township
Timber Hill Xing &
Highway/Street Pinnacle Drive Latitude(decimal degrees) N35.27100 Longitude(deamal degrees) W-78.97320
3. Approximate date land -disturbing activity will commence: Aril 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 0.63 acres
6. Amount of fee enclosed: $ 100.00 The application tee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900)
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes Enclosed _X] No
8 Person to contact should erosion and sediment control issues arise during land -disturbing activity -
Name Pamela Geddie E-mail Address Pam[ca cavinessandcates.com
Phone: Office # 910-778-7902 Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Anderson Creek Partners LP
Name
125 Whigipering Pines Dr
Current Mailing Address
Spring Lake NC 28390
City State Zip
910-814-2807
Phone: Office #
Current Street Address
Mobile #
Same
City State Zip
10. Deed Book No. 1346 Page No. 098 Provide a copy of the most current deed
Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive
list of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the
landowner(s) is an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Caviness & Cates Building and Development Co. Pam cavinessandcates.com
Company Name E-mail Address
639 Executive Place, Suite 400
Current Mailing Address
Fayetteville NC 28305
City State Zip
Same
Current Street Address
Same
City State Zip
Phone: Office # 910-481-0503 Mobile #
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and
sedimentation control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, 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
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(c) If the Financially Responsible Party is engaging in business under an assumed name, give name
under which the company is Doing Business As. If the Financially Responsible Party is an individual,
General Partnership, or other company not registered and doing business under an assumed name,
attach a copy of the Certificate of Assumed Name.
Company DBA Name
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(s) 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 Party). I
agree to provide corrected information should there be any change in the information provided
herein.
Patrick Raynor Chief Financial Officer
Ty7al�
ame Title or Authority
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Signature V Date
a Notary Public of the County of CAI Pv l LZ/ j OLI—Xj
State of North Carolina, hereby certify that A1 L OO/' appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him/her. }}
Witness my hand and notarial seal, this ipday P 20
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ary
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No#ary Public
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Cumberland county : My commission expires
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