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HomeMy WebLinkAboutNCC220662_FRO Submitted_20220215FINANCIAL RESPONSIBILITY/OWNERSHIP FORM SEDIMENTATION POLLUTION CONTROL ACT EXPRESS PERMITTING OPTION 08012007 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.) Part A. Calabash Meadows Senior Living Community 1. Project Name 2. Location of land -disturbing activity: County Brunswick City or TownshipCalabash Highway/StreetNW Calabash Rd Latitude78.5979 Longitude33 3. Approximate date land -disturbing activity will commence: March 2022 9151 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Senior Living Apartments 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.49 Amount of fee enclosed: $575.00 . The Express Permitting application fee is a dual charge. The normal fee of $65.00 per acre is assessed without a ceiling amount. In addition, the Express Permitting supplement is $250.00 per acre up to eight acres, after which the Express Permitting supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585). NOTE: Both fees are rounded up to the next whole acre and need to be paid by separate checks to NCDENR. Has an erosion and sediment control plan been filed? Yes No Enclosed^ 8. Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name -Holly Smith E-mail Address h011ylsmlth7@gmall.com Telephone919.363.1677 cell 4919.363.1677 Fax # 252.459.8197 9. Landowner(s) of Record (attach accompanied page to list additional owners): Ilex Calabash, LLC 919.363.1677 Name Telephone 909 Greenwood Circle Current Mailing Address Current Street Address Cary NC 27511 10 City State Zip City Deed Book No.4679 Page No.486 State 252.459.8197 Fax Number Zip 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. Ilex Calabash, LLC Name 909 Greenwood Circle Current Mailing Address Cary NC 27511 City hollylsmith7@gmail.com E-mail Address Current Street Address State Zip City State Telephone919.363.1677 Fax Number252.459.8197 Zip 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 (c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other consultant who can assist in providing any necessary information regarding the plan and its preparation: Engineering Firm or other consultant E-mail Address Individual contact person (type or print) 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. Holly L. Smith Managing Member Typ o print name Title or 7hority i natur Date --------- ----------------- ----------------------------------------------------------------------------------------------------------------------- I, 3-) v nt t a Notary Public of the County of State of North Carolina, hereby certify that 111[rm L appeared personally before me this day and being duly sworn acknowledge that the above form was executed by him. Witness my hand and notarial seal, this day of o 1, 20 ?JZ- �. KEVIN VARNELL / r Notary Public No p®alh Carolina Edgecombe County My commission expires N Z