HomeMy WebLinkAboutNCC223770_FRO Submitted_20221107No 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
2. Location of land -disturbing activity. County S'W�'j City or Township Mr, NI
PI
Highway/StreetTi4f&"Il.- Tir4d Latitude Longitude -8d -3S
3. Approximate date land -disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, institutional, etc.):
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3,11
6. Amount of fee enclosed: $ AC0'('C' _. 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 $685).
7. Has an erosion and sediment control plan been filed? Yes No - Enclosed
91
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Manny Perez E-mail Address- manny.p@carolinacarports.com
Telephone —Cell# 336-755-8249 Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
TPUT, 96\jA JL,-
LLC
Name Telephone Fax Number
Current Mailing Address
Current Street Address
DCA>50'I �c ;)-7c.(-7
City State Zip City state Zip
10. Deed Book No. �0 5— Page No. H03 — Provide a copy of the most current deed.
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):
Terra Nova Legacy, LLC manny.p@carolinacarports.com
Name E-mail Address
P.O. Box 636
Current Mailing Address Current Street Address
Dobson NC 27017
City State Zip City state Zip
Telephone 336-755-8249
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 E-mail Address
Current Mailing Address
City State Zip
Telephone
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
Telephone
E-mail Address
Current Street Address
City State Zip
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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.
M
Managing Member
Title or Authority
Date
LA 2091
7 SU d&A.!4 L - 6yo yn a Notary Public of the County of , I I
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State of North Carolina, hereby certify that Mont CA �4.rr_er& a V%Ore appeared
personally before me this day and being duty sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this —L—day of 20__aa_
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Notary 0 eft: PUBL`My commission expires 0'? Z3 Z A 0 �, -7
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