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HomeMy WebLinkAboutNCC233623_FRO Submitted_20231208 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 and/ or fax information unavailable, place N/A in the blank.) P1.art AProject Name Hidden Lake Lots 174-251 2. Location of land-disturbing activity: County Franklin City or TownshipYoungsviIIe Forest Bridge RdNalebrook Ct 36.0550 -78.4517 Highway/Street Latitude Longitude 3. Approximate date land-disturbing activity will commence:Decemeber 1st, 2023 4. Purpose of development(residential, commercial, industrial, institutional, etc.):Residential 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 15.67 Acres 6. Amount of fee enclosed: $ 1600.00 . The application fee of$100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount(Example: 8.10 ac=$900.00). 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: Name Andy Crawford E-mail Address acrawford@eastwoodhomes.com Telephone 919-427-2962 cell# 919-758-8208 Fax# 9. Landowner(s)of Record (attach accompanied page to list additional owners): Ange Executives Estates, LLC Name Telephone Fax Number PO Box 1801 301 Fayetteville Street, Suite 1900 Current Mailing Address Current Street Address Raleigh, NC 27602 Raleigh, NC 27601 City State Zip City State Zip 10. Deed Book No. 1915 Page No.454-457 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. Eastwood Homes of Raleigh, LLC acrawford@eastwoodhomes.com Name E-mail Address 7101 Creedmoor Road, Suite 115 7101 Creedmoor Road, Suite 115 Current Mailing Address Current Street Address Raleigh, NC 27613 Raleigh, NC 27613 City State Zip City State Zip Telephone(919) 758-8208 Fax Number(919) 647-4183 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 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. Type or print name Title or Authority ii/i5/23 Sign 'fe Date I,PGt"rn6L7t. , a Notary Public of the County of a-k-e--- State of North Carolina, hereby certify that Ai all C,t((Qu��1WG appeared personally before me this day and being duly worn acknowledged that the above form was executed by him. Witness my hand and notacjal, pal, this /3 day of J , 20 c -1 God; `S m ?, A %`''S ; = Notary Seal NOTARY • ptJBLtC V` My commission expires cg,3cSCA.f'1C XO&CP IU�E20rt'" l .