NCC221128_FRO Submitted_20220323

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.)
Part A.
1. Project Name Additions & Renovations to Moyock Middle School
2. Location of land -disturbing activity: County Currituck City or Township Moyock
Highway/Street Survey Rd. Latitude 36.5020° N Longitude-76.1570' W
3. Approximate date land -disturbing activity will commence: February 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Educational
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.13
6. Amount of fee enclosed: $L 300.00 . 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? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name E-mail Address
Telephone Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Currituck County Board of Education 252.232.2223
Name
PO Box 40
Current Mailing Address
Currituck NC 27929
Telephone
2958 Caratoke Hwy_
Current Street Address
Currituck NC
252.232.3655
Fax Number
27929
City State Zip City State Zip
10. Deed Book No. 510 Page No. 697 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.
Currituck County Board of Education [e-mail]
Name E-mail Address
_P_O Box 40 2958 Caratoke Hwy
Current Mailing Address Current Street Address
Currituck NC 27929 Currituck NC 27929
City State Zip City State Zip

Telephone [phone]
Fax Number 252.562.6974
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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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.
Karen R. Etheridge
Type or print name
Signs re
Chairman, Currituck County Bd. of Education
Title or Authority
Date
1, QUIAR-L a Notary Public of the County of
State of North Carolina, hereby certify that -LC.3 tj-7�•eA appeared
personally before me this day and being duly sworn acknowledged that the above f6rm was executed
by him.
Witness
.� c10TAlRy
MY
RES
PIJBOG
rial seal, this `day of c.-, , 21a_Z -Z
LA
Not
My commission expires