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HomeMy WebLinkAboutNCC223842_FRO Submitted_20221115FINANCIAL 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 Name Sagecroft 2. Location of land -disturbing activity: county Alamance City or Township Graham Highway/Street East Gilbreath Street Latitude(decimai degrees) 36.052406 Longitude(decimai degrees) -79.377088 3. Approximate date land -disturbing activity will commence: November 2022 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 33.0 AC 6. Amount of fee enclosed: $ 3,300.00 . 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). Checks should be addressed to NCDEQ. 7. Has an erosion and sediment control plan been filed? Yes IR Enclosed ❑ No ❑ 8. Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name Wesley Smith E-mail Address wesley.smith@lennar.com Phone: Office # 919-465-5935 Mobile # 919-608-7567 9. Landowner(s) of Record (attach accompanied page to list additional owners): AG EHC II (LEN) Multi State 1, LLC 704-413-3052 Name Phone: Office # Mobile # 160 Mine Lake Ct. Suite 200 160 Mine Lake Ct. Suite 200 Current Mailing Address Current Street Address Raleigh NC 27615 Raleigh NC 27616 City State Zip City State Zip 10. Deed Book No. 2878 Page No. 0990 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). Lennar Carolinas, LLC Company Name 1100 Perimeter Park Drive Suite 112 Current Mailing Address Morrisville NC 27560 City State Zip Phone: Office # 919-465-5935 troy.george@lennar.com E-mail Address 1100 Perimeter Park Drive Suite 112 Current Street Address Morrisville NC 27560 City State Zip 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: Corporate Creations Network Inc. contactus@corpereations.com Name of Registered Agent E-mail Address 15720 Brixham Hill Avenue #300 15720 Brixham Hill Avenue #300 Current Mailing Address Charlotte NC 28277 City State Zip Current Street Address Charlotte NC 28277 City Phone: Office # (561) 694-8107 Mobile # Trenton Bavaro Name of Individual to Contact (if Registered Agent is a company) State Zip (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 Current Mailing Address City State Phone: Office # E-mail Address Current Street Address Zip City Mobile # Name of Individual to Contact (if Registered Agent is a company) State Zip (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. Troy Geo Type or pr Signature Vice President Title or Authority /O L3 Z.2 -P, Date V it if Roz,.e l -,a Notary Public of the County of w �, State of North Carolina, hereby certify that val 6 'ed r —e- appeared personally before me this day and being duly sworn acknowledged that the above orm was executed by him/her. Witness my hand and notarial seal, this _day of ®C,'l7Jr 20 2Z `u1i1U1I i u►l►ilf/®�` Ro>!,, Seal,, % Not ry �a iARY os My commission expires 0 14n �c V p'p'i C O 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 # 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 3 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 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 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. Continued from Item 1 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 Zip City State Phone: Office # Mobile # Company 3 Name E-mail Address Current Mailing Address Current Street Address City State Zip Zip City State Phone: Office # Mobile # Company 4 Name E-mail Address Current Mailing Address Current Street Address - City State Zip Zip City State Phone: Office # Mobile # Company 5 Name E-mail Address Current Mailing Address Current Street Address City State Zip Zip City State Phone: Office # Mobile #