HomeMy WebLinkAboutNCC222582_FRO Submitted_20220728FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 Great Meadows, LLC Waste Site off of Bridgewater Road
2. Location of land -disturbing activity: County Burke City or Township Silver Creek
Bridgewater Rd. N-35.71805 w-81.85738
Highway/Street g LatltUde�dedma�dagreas) LOngltUde(dedmaldegrees)
3. Approximate date land -disturbing activity will commence: Summer, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.). Waste Site
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.9 Acres
6. Amount of fee enclosed $ 700.00 . The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition, the Express Permitting supplement is $250 per acre up to eight acres, afterwhich the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900). 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 Byron Phillips E-mail Address gbphillipS@bellsouth.net
Phone: Office # 828-765-9086 Mobile # 828-766-7824
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Great Meadows, LLC 828-765-9086 828-766-7824
Name
P.O. Box 400
Current Mailing Address
Spruce Pine, NC 28777
Phone: Office # Mobile #
12019 South 226 Hwy.
Current Street Address
Spruce Pine, NC 28777
City State Zip City State Zip
785
10. Deed Book No. Page No. "-- Provide a copy of the most current deed.
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Great Meadows, LLC
Company DBA Name
(d) If 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`
West Consultants, PLLC
Engineering firm or other consultant
David W. Poore, PE, CPESC
Individual contact person (type or print)
dpoore@west-consultants.com
E-mail Address
828-522-4729 828-766-4772
Phone: Office # Mobile #
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.
Byron Phillips
Type or print me
ig ure
Manager
Title or Authority
l-'2y-z6Zz
Date
I, idnzi% A Vnps�, a Notary Public of the County of r 111 �Che� 1
State of North Carolina, hereby certify that Phi)11%6 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 l day of , 20�
o
Notary
Seal My commission expires 'Ap a 1p
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 orif the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Great Meadows, LLC
Company Name
P.O. Box 400
Current Mailing Address
Spruce Pine, NC 28777
City State Zip
Phone: Office # 828-765-9086
gbphi[lips@bellsouth.net
E-mail Address
12019 South 226 Hwy.
Current Street Address
Spruce Pine, NC 28777
City
State
Mobile # 828-766-7824
Zip
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:
Byron Phillips gbphillips@bellsouth.net
Name of Registered Agent
P.O. Box 400
E-mail Address
12019 South 226 Hwy.
Current Mailing Address Current Street Address
Spruce Pine, NC 28777 Spruce Plne, NC 28777
City State Zip City
State Zip
Phone: Office # 828-765-9086 Mobile # 828-766-7824
Byron Phillips
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
Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record.
Name Phone: Office #
Current Mailing Address Current Street Address
Mobile #
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 3 of Record:
Name
Current Mailing Address
Phone: Office #
Current Street Address
Mobile #
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 4 of Record:
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No, Page No. Provide a copy of the most current deed_
Landowner 5 of Record:
Name
Current Mailing Address
Phone: Office # Mobile #
Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Continued from Item 9 in Part 8 of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City
Phone: Office # Mobile #
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City
Phone: Office # Mobile #
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State
Phone: Office #
State
State
Zip City State
Mobile #
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City
Phone: Office # Mobile #
State
Zip
Zip
Zip
Zip