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HomeMy WebLinkAboutNCC223094_FRO Submitted_20220921Firefox about:blank FINANCIAL 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 N/A in the blank.) Part A. 1. Project Name Manners Subdivision 2. Location of land -disturbing activity: County Franklin City or Township NSA Highway/Streetshearin LEI Latitude(decimaidegrees) 35.99966 Long itude(dearnal degrees) -78.35934 3. Approximate date land -disturbing activity will commence: August 2022 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1 1.3 6. Amount of fee enclosed $3,200 . 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, after which 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. 7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑ 8. Person to contact should erosion and sediment control issues arise during land -disturbing activity: E-mail Address Name Cyrus Dennis Cy dennis@grandemanorhomes.com Phone: Office # 919-669-5933 Mobile # Same 9. Landowner(s) of Record (attach accompanied page to list additional owners): Shearin Lane LLC 919-669-5933 Same Name Phone: Office # Mobile # 1151 Tarboro Rd Same Current Mailing Address Current Street Address _Youngsville, NC 27596 Same City State Zip City State Zip 10, Deed Book No. 2288 Page No. 819 Provide a copy of the most current deed. 1 of 5 7/7/2022, 1:28 PM Firefox about:blank 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.) If the 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). Shearin Lane LLC dennisagrandemanorhomes.com Company Name E-mail Address 1151 Tarboro Rd Same Current Mailing Address Current Street Address Youngsville, NC 27596 Same City State Zip City State Zip Phone: Office # 919-669-5933 Mobile # Same 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 2 of 5 7/7/2022, 1:28 PM Firefox about:blank 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: FLM Engineering, Inc. Engineering firm or other consultant Jon Frazier Individual contact person (type or print) jfrazier@flmengineering.com E-mail Address 919-610-1051 Same Phone: Office # Mobile # 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 attomey-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. Dennis Cyrus Type r rint name Signature Member Manager Title or Authority Date S;[ c�a Notary Public of the County of State of North Carolina, hereby certify that _.Vt % VIC ,S appeared personally before me this day and being duly sworn acknowledged that the Above form was executed by him/her- Witness my hand and notarial seal, this (2day of 20 Notary Seal �g00 My commission expires a 2o.94 14f4o �. o G 'Z�� cap 3 of 5 7/7/2022, 1:28 PM