HomeMy WebLinkAboutNCC221220_FRO Submitted_20220404FINANCIAL 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 Environment and Natural Resources. (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.
1. Project Name Western Piedmont Community College Skilled Trades Solution Center
2. Location of land -disturbing activity: County Burke City or Township Mor anton
Highway/Street 1001 Burkemont Ave. Latitude 35.722193 Longitude-81.692555
3. Approximate date land -disturbing activity will commence:_ May 1 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Institutional
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.42
6. Amount of fee enclosed: $ 195.00 . 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 YES No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Eii'ah Cook E-mail Address eli'ahcook _midstatecontractors net
Telephone 828-228-3556 Cell # Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
Western Piedmont Community College 828-448-3500
Name Telephone Fax Number
1001 Burkemont Ave 1001 Burkemont Ave.
Current Mailing Address Current Street Address
Morganton NC 28655 Morganton NC 28655
City State Zip City State Zip
10. Deed Book No. 271 Page No. 242 Provide a copy of the most current deed.
Part B.
Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Midstate Concractors INC elijahcook@midstatecontractors.net
Name E-mail Address
PO Box 1238 . 3245 Highway 70 SE
Current Mailing Address Current Street Address
Hickory NC 28603 Hickory NC 28603
City State Zip City State Zip
Telephone 828-228-3556 Fax Number
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 State Zip
Telephone
E-mail Address
Current Street Address
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 State Zip
Telepho
E-mail Address
Current Street Address
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.
- I' �- Coe +l
Typ,& or print name
ignature
Title or Auth rity
Date
I, y' a Notary Public of the County of L Y�bq
State of North Carolina, hereby certify that t 4 _OLh appeared
personally before me this day and being duly sworn abknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this a day of kA6LrLj,-N , 20 / �-
R%E C •••.
'.O�
'• o OTa o? Notary
A My commission expires —
;A
COUP
Illllf) YMM/l1\l�►