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HomeMy WebLinkAboutNCC223254_FRO Submitted_20220922FINANCIAL RESPONSIBILITY/OWNERSHIP FORM SEDIMENTATION POLLUTION CONTROL ACT EXPRESS PERMITTING OPTION 11192021 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. Baker Preserve Subdivision 1. Project Name 2. Location of land -disturbing activity: County Franklin City or Township Louisburg Highway/Street US Highway 401 S Latitude 35.98 N Longitude -78.39 W 3. Approximate date land -disturbing activity will commence: September 2022 4. Purpose of development (residential, commercial, industrial, institutional, etc.) Residential 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 7.0 AC 6. Amount of fee enclosed: $ $2,700.00 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 X 8. Person to contact should erosion and sediment control issues arise during land -disturbing activity: NameMichael A. Moss E-mail Address mike@cmppls.com 919-556-3148 n/a n/a Telephone Cell # Fax # 9. Landowner(s) of Record (attach accompanied page to list additional owners) Baker Development, LLC n/a n/a Name Telephone Fax Number PO BOX 610 n/a Current Mailing Address Current Street Address Youngsville NC 27596 n/a n/a n/a City State Zip City State Zip 10. Deed Book No. 2296 Page No. 692 & 740 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 Baker Development, LLC mike@cmppls.com Name PO BOX 610 Current Mailing Address Youngsville NC 27596 City State 919-556-4700 Telephone E-mail Address n/a Current Street Address n/a n/a n/a Zip City n/a 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: Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Telephone 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 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: FLM Engineering, Inc cmassey@flmengineering.com Engineering Firm or other consultant E-mail Address Chase Massey, PE 919-423-8975 Individual contact person (type or print) Telephone nla 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. Michael Moss Type or print name Signature Member Title or Authority 7- zS�ZZ Date I, �� (n • 1 I o V_c - , a Notary Public of the County of WC. oc L State of North Carolina, hereby certify than L� G►��� appeared personally � before me this day and being duly sworn acknowledged that the above form was executed by him. Witness my hand and note Seal of , 20,1a N ary My commission expires 4 7. LDz