NCC221238_FRO Submitted_20220421

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 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: Fire Station 4
2. Location of land -disturbing activity: County Cumberland City or Township Fayetteville
Highway/Street NC 24 Latitude 35°05'01"N Longitude-78°56'45.5"W
3. Approximate date land -disturbing activity will commence: March 2022 -
4. Purpose' of development (residential, commercial, industrial, institutional, etc.): Municipal
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.21
6. Amount of fee enclosed: $300.00 . The application fee of $100.00 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 Rob Stone, PE E-mail Address RobertStone(c FayettevilleNC.gov
Telephone [phone] Cell # 910-818-9146
Landowner(s) of Record (attach accompanied page to list additional owners):
City of Fayetteville
Name
433 Hay Street
Current Mailing Address
Fayetteville NC 28301-5537
City State Zip
910-433-1990
Telephone
433 Hay Street
Current Street Address
Fax #
Fax Number
Fayetteville NC 28301-5537
City State Zip
10. Deed Book No. 10743 Page No. 514 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):.
City of Fayetteville, Doug Hewett, City Mgr,.
Name
433 Hay Street
Current Mailing Address
Doug Hewett,aDFavettevi11eNC.gov
E-mail Address
433 Hay Street
Current Street Address
Fayetteville NC 28301-5537 Fayetteville NC 28301-5537
City State Zip City State Zip
Telephone [phone] 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
E-mail 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
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.
Doua Hewett City Manager
Type or rint na e Title or Aut rity
ZCp Z
Sig ure j Date
I, a Notary Public of the County of
State of North Carolina, hereby certify that V . appeared
personally before me this day and being duly sworn ack wledged that the above form was executed
by him.
Witness my hand and notarial seal, this
Seal
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