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HomeMy WebLinkAboutNCC240668_FRO Submitted_20240307 Check if this project is ARPA-funded ❑ Attach a copy of the Letter of Intent to Fund 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 Wrightsville Blvd, Phase 2 Water and Stormwater Improvements *If this project involves American Rescue Plan Act(ARPA) funds, list the Project Name or Project Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the Division of Water Infrastructure (DWI). 2. Location of land-disturbing activity: County Dare City or Township Kill Devil Hills Wrightsville Blvd 36°00'00"N 75°39'06"W Highway/Street Latitude(decimaldegre3 LOngitude(decimaldegrees) 3. Approximate date land-disturbing activity will commence: September 3, 2024 4. Purpose of development(residential, commercial, industrial, institutional, etc.):_ Municipal 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1.42 AC 6. Amount of fee enclosed: $ 200.00 . 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 ❑ Enclosed 1 No ❑ 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name Derek A. Dail,Ass't Public Services Director E-mail Address derek@kdhnc.com Phone: Office# 252-480-4080 Mobile# 252-216-7471 9. Landowner(s)of Record (attach accompanied page to list additional owners): Town of Kill Devil Hills, NC 252-480-4080 Name Phone: Office# Mobile# P.O Box 1719 102 Town Hall Drive Current Mailing Address Current Street Address Kill Devil Hills NC 27948 Kill Devil Hills NC 27948 City State Zip City State Zip 10. Deed Book No. Page No. Provide a copy of the most current deed. No deed book/page is applicable; all work is within public street right of way dedicated to KDH by subdivision plat. Part B. i a 1. Company(ies)who are financially responsible for the land disturbing activity(Provide a comprehensive list a of all responsible parties on accompanied page.)If the company is a sole proprietorship or if the landowner(s)is I an individual(s), the name(s)of the owner(s)may be listed as the financially responsible party(ies). ° Town of Kill Devil Hills b. C/O Public Services Department derek@kdhnc.com Company Name E-mail Address P.O Box 1719 107 Town Hall Drive Current Mailing Address Current Street Address Kill Devil Hills NC 27948 Kill Devil Hills NC 27948 ( City State Zip City State Zip Phone: Office# 252-480-4080 Mobile# 252-216-7471 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: N/A Name of Registered Agent E-mail Address N/A Current Mailing Address Current Street Address N/A City State Zip City State Zip Phone: Office# N/A Mobile# N/A 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: N/A Name of Registered Agent E-mail Address N/A Current Mailing Address Current Street Address f N/A City State Zip City State Zip ( Phone: Office# N/A Mobile# N/A r t, Name of Individual to Contact(if Registered Agent is a company) i' 1 H 4'. (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. i 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. i'''', Derek A. Dail Kill Devil Hills Assistant Public Services Director Type or print name Title or Authority ...mk,---___ 4,....,.--- / 10/ /20241 Signature Date j. I, 6'1 ,i ( 16} , a Notary Public of the County of )Thakt, State of North Carolina, hereby certify that .Jett T� , . �1i � 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 Ci l.. ` day of -.)t ltcu2 4 , 202/— I JAMES MICHAEL O'DELL i 4 Notary Public-North Carolina M " IOta „E1 Dare County ( ` My Commission Expires May 4, 2025 ) 3 My commission expires �- ) 1 ( 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: 111 ::1 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 9 in Part B 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 City State Zip Phone: Office# Mobile# Company 3 Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office# Mobile# Company 4 Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office# Mobile# Company 5 Name E-mail Address Current Mailing Address Current Street Address :' City State Zip City State Zip Phone: Office# Mobile# i 1 1 M1