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HomeMy WebLinkAboutNCC215504_FRO Submitted_20211005FINANCIAL RESPONSIBILITYIOWNERSHIP 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 NIA in the blank.) Part A. East River PH 6 & 7 1. Project Name 2. Location of land -disturbing activity: County�ohnSton City or Township Smithfield Highway/Street Buffalo Road - SR 1003 Latitude 35.5350 Longitude - 78-3303 3. Approximate date land -disturbing activity will commence: 9-29-2021 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 7.70 AC 6. Amount of fee enclosed: $520 . The application fee of $65.00 per acre (rounded up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585). 7. Has an erosion and sediment control plan been filed? YesXX No Enclosed 8. Person to contact should erosion and sediment control issues arise during land -disturbing activity: NameNick MCKeel E-mail Address nick.mckeelQprovidence.00nstruction Telephone NA Cell # 919-429-0245 Fax # NA 9. Landowner(s) of Record (attach accompanied page to list additional owners): Buffalo Road, LLC 919-901-3178 NA Name Telephone Fax Number 114 W. Main Street 114 W. Main Street Current Mailing Address Current Street Address Clayton, NC 27520 Clayton, NC 27520 City State Zip City State Zip 10. Deed Book No. 5203 page No. 208 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 orrrm is a sole proprietorship, the name of the owner or manager may be listed as the financially responsible party. Buffalo Road, LLC dave@hearthpointe.com Name E-mail Address 114 W. Main Street 114 W. Main Street Current Mailing Address Current Street Address Clayton, NC 27520 Clayton, NC 27520 City State Zip City State Zip Telephone 919-901 -3178 Fax NumberNA 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 Telephone City Fax Number State Zip 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. Reid Smith Managing Member Type or print name iAd=5�L Srgnature Title or Authority 9/29/21 Date I, T21 l , a Notary Public of the County of� State of North Carolina, hereby certify that W, 6 'k 'fl appeared personally before me this day and being duly sworn acknowledged that the above form was executed by him. Witness my hand and 9,tarial seal, this day of , 213� %ti i uugii �LEJ�ua ary '°Ui3L1C My commission expires] �2�