HomeMy WebLinkAboutNCC222485_FRO Submitted_20220708FINANCIAL 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 and/or fax information
unavailable, place N/A in the blank.)
Part A.
1. Project Name The Tides
2. Location of land -disturbing activity: County Brunswick City or Township Shallotte
Highway/Street Smith Ave - NC 130 Latitude 39.97443 Longitude -78.37441
3. Approximate date land -disturbing activity will commence: May 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 36 AC
6. Amount of fee enclosed: $ 3600.00 . The application fee 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).
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 Casey King E-mail Address casey@cavinessandcates.com
Telephone_910.481.0503 Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
The Tides of Shallotte, LLC 910.481.0503
Name Telephone Fax Number
639 Executive Place, Suite 400 639 Executive Place, Suite 400
Current Mailing Address Current Street Address
Fayetteville NC 28305 Fayetteville NC 28305
City State Zip City State Zip
10. Deed Book No. 4810 Page No. 0410 - 0413 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.
The Tides of Shallotte, LLC casey@cavinessandcates.com
Name E-mail Address
639 Executive Place, Suite 400 639 Executive Place, Suite 400
Current Mailing Address Current Street Address
Fayetteville NC 28305 Fayetteville NC 28305
City State Zip City State Zip
Telephone 910.481.0503
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
Telephone,
E-mail Address
Current Street Address
State Zip 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
Telephone.
E-mail Address
Current Street Address
State 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.
J. Patrick Raynor
Type or print name
�i
Sign ure
Registered Agent
Title or Authority
V/i/ 1z
Date
I, _ bAe_4A2_ i'!CLiPC/1J a Notary Public of the County of (I1Y] ep/an
State of North Carolina, hereby certify that J_- �LZTI`/ L' appeared
personally before me this day and being duly sworn acknowledged th t the above form was executed
by him.
Witness,T ito notarial seal, this day of r" 20 a o'ty
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