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HomeMy WebLinkAboutNCC230200_FRO Submitted_20230125FINANCIAL 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 N/A in the blank.) Part A. 1. Project Name KPG Properties, LLC - Dental Office 1007 Newman Rd 2. Location of land -disturbing activity: County Craven City or Township New Bern Highway/Street 1 007 Newman Rd Latltude(decimal degrees) 35.1067 Longltude(decimal degrees) 77.0915 3. Approximate date land -disturbing activity will commence: November 21, 2022 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.50 6. Amount of fee enclosed: $ 200 . 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. 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: Name Bobby Evans - Farrior & Sons, Inc E-mail Address bobby@farriorandsons.com Phone: Office # 252-753-2005 Mobile # 252-531-9000 9. Landowner(s) of Record (attach accompanied page to list additional owners): KPG Properties, LLC 252-636-0011 252-671-5559 Name Phone: Office # Mobile # William Kincaid - Member -Manager 635 McCarthy Blvd Current Mailing Address Current Street Address 635 McCarthy Blvd New Bern NC 28562 City State Zip City State Zip 10. Deed Book No. 3745 Page No. 1598-1600 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 companyis a sole proprietorship orif the landowner(s) is an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies). KPG Properties, LLC Company Name 635 McCarthy Blvd Current Mailing Address New Bern NC 28562 bilkincaid@hotmail.com E-mail Address 635 McCarthy Blvd Current Street Address New Bern NC 28562 City State Zip City Phone: Office # 252-636-0011 Mobile # State Zip 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 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. William Kincaid) '�Member-Manager KPG Properties, LLC Type or p/riot name � c Signature Title or Authority �/- 9 -- Date ------- I, ��� S • �rink�eLl a Notary Public of the County of CraV e_Yk State of North Carolina, hereby certify that W; 1 � i M KA O n Ga I cl -VT—appeared personally before me this day and being duly sworn acknowledged that the above form 'was by him/her. Witness my hand and notarial seal, this V- day of l�D , 20 `Z-`L Notary 4,41 L ' My commission expires_ �DWS�2OL Ug L1C ��� �Intq J�� 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. Name Phone: Office # Mobile # Current Mailing Address Current Street Address City State Zip City State Zip Deed Book No. Page No. Provide a copy of the most current deed. Landowner 3 of Record: Name Phone: Office # Mobile # Current Mailing Address Current Street Address City State Zip City State Zip Deed Book No. Page No. Provide a copy of the most current deed. Landowner 4 of Record: Name Phone: Office # Mobile # Current Mailing Address Current Street Address City State Zip City State Zip Deed Book No. Page No. Provide a copy of the most current deed. Landowner 5 of Record: Name Phone: Office # Mobile # Current Mailing Address Current Street Address City State Zip City State Zip Deed Book No. Page No. Provide a copy of the most current deed. Continued from Item 1 in Part 8 of the Financial Responsibility/Ownership Form for multiple parties. Attach copies of this page as needed to list all financially responsible parties. Company 2 Name Current Mailing Address E-mail Address Current Street Address City State Zip City Phone: Office # Mobile # Company 3 Name Current Mailing Address E-mail Address Current Street Address City State Zip City Phone: Office # Mobile # Company 4 Name Current Mailing Address E-mail Address Current Street Address City State Zip City Phone: Office # Mobile # Company 5 Name Current Mailing Address E-mail Address Current Street Address State Zip State Zip State Zip City State Zip City State Zip Phone: Office # Mobile #