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HomeMy WebLinkAboutNCC231079_FRO Submitted_20230417 Check if this project is ARPA-funded ❑ 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, including any activity under a common plan of development of this size as covered by the NCG01 permit, 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 Survey for CBS Ventures LLC Subdivision - Lots 1 15 *If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below under which you applied for funding through the Division of Water Infrastructure (DWI). 2. Location of land-disturbing activity: County Sampson City or Township Dismal Township Minnie-Hall Road SR 1414 & Highway/StreetSivertsen Rd SR-1425Latitude(decimal degrees)N 35.03230 Longitude(decimal degrees)W-78.6285° 3. Approximate date land-disturbing activity will commence: March 2023 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 14.53 Acres 6. Amount of fee enclosed: $ 1,500 . 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. 3. . 7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed iX No ❑ 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name Hannah McGrath E-mail Address permittinq(a�benstoutconstruction com Phone: Office# 910-779-0019 Mobile # 9. Landowner(s) of Record (attach accompanied page to list additional owners): CBS Ventures LLC 910-891-4464 Name Phone: Office # Mobile# 2905 Hampton Ridge Road Same Current Mailing Address Current Street Address Fayetteville NC 28311 Same City State Zip City State Zip 10. Deed Book No. 2134 Page No. 007 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). Benjamin Stout Real Estate Services Inc briannbenstoutconstruction com Company Name E-mail Address 1786 Metromedical Drive Same Current Mailing Address Current Street Address Fayetteville NC 28304 Same City State Zip City State Zip Phone: Office# 910-779-0019 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: 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) (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. Brian D. Walker President Type or print name Title or Authority ".l 4 1 L'q123 Signature Date ------------------------------------------------------------------------------------- I, a Notary Public of the County of alb 1 State of North Carolina, hereby certify that t't!'rtl !J. 1 r-f 1�kc 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 r day of (' prcy 20 NDA F zaA�, �,ornmfss o.`�q'' Notary ► °F`'�O c NOTq = My commission expires11a A Ry : (n 0.6 118CIC _ z..f�•2d�Y 12 V)" rG C ...... ...••'a