HomeMy WebLinkAboutNCC230060_FRO Submitted_20230112FINANCIAL 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 Hiahcroft Lots 223, 224, 225, 226 and 300
2. Location of land -disturbing activity: County Cumberland City or Township Grays Creek
Highway/Street Lunsford Drive Latitude(decimal degrees)35.039228 Longitude(decimal degrees)79.073376
3. Approximate date land -disturbing activity will commence: December 22, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.04 acres
6. Amount of fee enclosed $200.00 + $500.00. 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 X Enclosed X No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Watson Caviness E-mail Address pi(o)-cavinessland.com
Phone: Office # 910-339-6330 Mobile # 910-237-0572
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Caviness Land Development, Inc. 910-339-6330 910-237-0572
Name Phone: Office # Mobile #
1041 B Robeson St
Current Mailing Address
Fayetteville NC 28305
City State Zip
1041 B Robeson St
Current Street Address
Fayetteville NC 28305
City State Zip
10. Deed Book No. 11635 Page No. 107 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).
Caviness Land Development, Inc.
Company Name
1041 B Robeson St
Current Mailing Address
Fayetteville NC 28305
City State Zip
pj(o),cavinessland.com
E-mail Address
1041 B Robeson St
Current Street Address
Fayetteville NC 28305
City State Zip
Phone: Office # 910-339-6330 Mobile # 910-237-0572
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
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(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
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(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 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:
Engineering firm or other consultant
Individual contact person (type or print)
E-mail Address
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 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 ;nformation should there be any change in the information provided
herein.
Watson Caviness
Type or print name
Signature
Manager/Owner
Title or Authority
12/19/2022
Date
I, Lori Simpson Epler , a Notary Public of the County of Cumberland
State of North Carolina, hereby certify that Watson Caviness 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 19 th day of December , 2022
E
licNotary
My commission expires 11/14/2024
ountyioa
Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record
Highcroft of Fayetteville, LLC 910-339-6330 910-339-6330
Name Phone: Office # Mobile #
2919 Breezewood Avenue #100 2919 Breezewood Avenue #100
Current Mailing Address Current Street Address
Fayetteville NC 28303 Fayetteville NC 28303
City State Zip City State Zip
Deed Book No. 10197 Page No. 75 Provide a copy of the most current deed.
Landowner 3 of Record:
Name
Current Mailing Address
City
Deed Book No.
Landowner 4 of Record:
Name
Current Mailing Address
State Zip
Page No.
City State
Deed Book No.
Landowner 5 of Record:
Name
Current Mailing Address
Zip
Page No.
Phone: Office # Mobile #
Current Street Address
City State Zip
Provide a copy of the most current deed.
Phone: Office # Mobile #
Current Street Address
City
State Zip
Provide a copy of the most current deed.
Phone: Office # Mobile #
Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.