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HomeMy WebLinkAboutNCC223835_FRO Submitted_20221115FINANCIAL 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 address or phone number is unavailable, place NIA in the blank,) Part A. Project Name McCor uodale Subdivision - Lots 1 & 2 2. Location of land -disturbing activity: County Cumberland City or Township Black River Township Stewart Road Highway/Street (SR-1819) Latitude(dec;mal degrees) N 35.1678° Long itu de(dearnal degrees) W-78.6546° 4 J. 0 Approximate date land -disturbing activity will commence: November 2022 Purpose of development (residential, commercial, industrial, institutional, etc.): Residential Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.92 Acres Amount of fee enclosed: $ 200.00 . The application fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900). Checks should be addressed to NCDEQ. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed M No ❑ Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name Leanna Hair E-mail Address_ leannahair(aonsitehomesnc.com Phone: Office # 910-745-0001 Mobile # Landowner(s) of Record (attach accompanied page to list additional owners): Frankie Buzz McCorquodale & Misty Hales McCorouodale Name Phone: Office # Mobile # 210 Parkview Avenue Current Mailing Address Fayetteville NC 28305 City State Zip Current Street Address Same City State Zip 10. Deed Book No. 11439 Page No. 704 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.) 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). Onsite Homes LLC Company Name 2931 Breezewood Avenue Suite 202 Current Mailing Address Fayetteville NC 28303 City State Zip Phone: Office # 910-745-0001 nediohnson@onsitehomesnc_com E-mail Address Same Current Street Address Same City State Zip Mobile # 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 Current Mailing Address City State Zip Phone: Office # E-mail Address Current Street Address City State Zip 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) M 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 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. Nathanj@Lj9ftWn Typ r print nam Signatur V State of North Carolina, personally before me this executed by him/her. Witness my hand and Managing Member Title or Authority i 25 - Z2 Date C.� a Notary �Plublic of the County of , )V-- .( Y« hereby certify that Q !`L-i1 appeared day and being duly sworn acknowledge that the above form was is 257>dc