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HomeMy WebLinkAboutNCC223571_FRO Submitted_2022101910. Deed Book No. 3728 Page N FINANCIAL 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 N/A in the blank.) Part A. 1. Project NameThales Academy at West New Bern 2. Location of land -disturbing activity: County Craven City or Township New Bern Clock Drive 35.132796-77.121028 Highway/Street Latltude(decimal degrees) LOngltUde(decimal degrees) 3. Approximate date land -disturbing activity will commence: Summer 2022 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Institutional 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 8.30 6. Amount of fee enclosed: $ 900 . 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). Checks should be addressed to NCDEQ. 7. Has an erosion and sediment control plan been filed? Yes ❑x Enclosed p No ❑ 8. Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name Kevin Varnell E-mail Address Warnell@stocksengineering.com Phone: Office # 252-459-8196 Mobile # 252-382-0012 9. Landowner(s) of Record (attach accompanied page to list additional owners): Thales Academy 919-427-1646 Name 4641 Paragon Park Rd. Current Mailing Address Raleigh, NC 27616 City State Zip City 046 Phone: Office # Mobile # 4641 Paragon Park Rd. Current Street Address Raleigh, NC 27616 State Zip Provide a copy of the most current deed. 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). Company Name 4641 Paragon Park Rd. Current Mailing Address Raleigh, NC 27616 City State Zip Phone: Office # E-mail Address 4641 Paragon Park Rd. Current Street Address Raleigh, NC 27616 City State 0I 0 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: Name of Registered Agent 4641 Paragon Park Rd. Current Mailing Address Raleigh, NC 27616 City State Zip Phone: Office # brandon.hafner@captiveaire.com E-mail Address 4641 Paragon Park Rd. Current Street Address Raleigh, NC 27616 City State Zip Mobile #919-427-1646 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. Robert L. Luddy Registered Agent Title or Authority Date- � � agT /D, 2 o Z Z -------- -------------------------------------------------- a Notary Public of the County of j State of North Carolina, hereby certify that ISC> --� �- L-(,> 01 ° appeared personally before me this day and being duly sworn acknowledged that the abo form was executed by him/her. Witness my hand and notarial seal, 111M �,*Seal _ NOTARy _ PU13LIC' — C)UNlllw,� this day of 1141AN4, 202- ',Jl L Notary My commission expires