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HomeMy WebLinkAboutNCC223711_FRO Submitted_20221031FINANCIAL 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 NIA in the blank.) Part A. The 203 Project 1. Project Name 2. Location of land -disturbing activity: County Orange City or Township Town of Carrboro Highway/Street sGreensboro Street (8R1919) Latitude 35054'33.65"N Longitude790 4'18.79"W 3. Approximate date land -disturbing activity will commence: O 1 /0 1 12 022 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Public - Mixed Use 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.25 acres 6. Amount of fee enclosed: $ 130 . 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 Ben Schmadeke E-mail Address bschmadeke@townofcarrboro.org Telephone 919-918-7424 Cell # 919-637-8056 Fax # 919-968-7728 9. Landowner(s) of Record (attach accompanied page to list additional owners): Town of Carrboro 919-918-7333 Name Telephone Fax Number 301 W Main Street 301 W Main Street Current Mailing Address Current Street Address Carrboro, NC 27510 Carrboro, NC 27510 City State Zip City State Zip 10. Deed Book No. 5582 Page No. 486 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. Town of Carrboro Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Telephone 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: NIA Name E-mail Address Current Mailing 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 Part is a Corporation, give name and street address of the Registered Agent: NA Name of Registered Agent E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Telephone 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. Arche L. McAdoo Chief Finance Officer Type t name Title or Authority .� i i /n9on9 i Signature Date I, _ MA KS14A ice- ATE , a Notary Public of the County of 6 9AM &i State of North Carolina, hereby certify that _ personally before me this day and being executed by him. A rzoq E L. A4C Vivo appeared duly sworn acknowledged that the above form was �D Witness my hand and notarial seal, this day of�/. _J�0VeU;,0 , 20ft.),4 - '/z� 'V, 6'6� tart' MAIM PATE NOTARY PUBLIC My commission expires ORANGE COUNTY, NC COMMISSION EXPIRES JUNE 20, 2024