Loading...
HomeMy WebLinkAboutNCC221234_FRO Submitted_20220407FINANCIAL RESPONSIBILITY/OWNERSHIP FORM SEDIMENTATION POLLUTION CONTROL ACT EXPRESS PERMITTING OPTION 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 address or phone number is unavailable, place NIA in the blank.) Part A. Project Name Carriage Place Townhomes - Individual Lot Construction 2. Location of land -disturbing activity: County Moore City or Township Carthage Highway/Street Gracie Lane Latitude(decimai degrees) 35.327778Long itude(decimal degrees)-79.408611 3. Approximate date land -disturbing activity will commence: March 2022 4. Purpose of development (residential, commercial, industrial, institutional, etc.): residential 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.0 acres 6. Amount of fee enclosed $1,400.00 . The Express Permitting application fee is a dual charge. The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount. In addition, the Express Permitting supplement is $250 per acre up to eight acres, afterwhich the Express Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900). Checks should be addressed to NCDEQ. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed X No ❑ Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name Jessica Meyer E-mail Address JAMeyer@drhorton.com Phone: Office # (919) 460-2999 Mobile # (919) 215-6561 Landowner(s) of Record (attach accompanied page to list additional owners): DR Horton, Inc. Name 2000 Aerial Center Parkway, Suite 110A Current Mailing Address _Morrisville NC 27560 City State Zip (919) 460-2999 (919) 215-6561 Phone: Office # Mobile # 2000 Aerial Center Parkway, Suite 110A Current Street Address Morrisville NC 27560 City State 0 10. Deed Book No. 5784 Page No, 80 Provide a copy of the most current deed. Part B. 1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list of all responsible parties on accompanied page.) lithe company is a sole proprietorship or if the landowner(s) is an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies). D.R. Horton Inc. Company Name 2000 Aerial Center Parkway, Suite 110A Current Mailing Address Morrisville NC 27560 City State Zip Phone: Office # 919-460-2999 JAMeyer@drhorton.com E-mail Address 2000 Aerial Center Parkway, Suite 110A Current Street Address Morrisville NC City State Mobile # (919) 215-6561 27560 Zip 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: Name of Registered Agent E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office # Mobile # 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: Name of Registered Agent E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office # Mobile # Name of Individual to Contact (if Registered Agent is a company) (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. Company DBA Name (d) If 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: Ark Consulting Group, PLLC Engineering firm or other consultant Scott T. Anderson, PE Individual contact person (type or print) scotto_arkconsultinggroup.com E-mail Address 252-258-0734 Phone: Office # Mobile # 252-565-1015 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. ess igLc ](pDE-S Thin [ c w l Cov',P liana , ini si- '� Type or print nanhC Title or Authority A� '- ig ature Date ---------------------- -------------------------------------------------------------------------------------------------------------- 1,(�&,¢�Y or_77,a Notary Public of the County of TLjt�,) J7 State of North Carolina, hereby certify than e_5s 111—A appeared personally before me this day and being duly sworn acknowledged that the allove form was executed by him/her. 4 Witness my hand and notarial seal, this day of 20,24�._ Notary NOTARY f UBUG t e15I►�A K. I�o�SlN 3 My commission expires FORSYTN COUNTY, NC lay Corrvms3Von Ex�rea �— Continued from Items 9 & 90 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: 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 1 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 Current Mailing Address City Phone: Office # Company 3 Name Current Mailing Address E-mail Address Current Street Address State Zip City State Mobile # E-mail Address Current Street Address Zip 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 #