HomeMy WebLinkAboutNCC230281_FRO Submitted_20230131FINANCIAL 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 McLain Subdivision
2. Location of land -disturbing activity: County CabarrUS City or Township IKannap011s
McLain Road 35.48389-80.60583
Highway/Street LatltUde(decima� degrees) LOngltUde(decimaldegrew)
3. Approximate date land -disturbing activity will commence: June 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.801
6. Amount of fee enclosed $1,050 . 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 ❑ Enclosed M No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name George Fountas E-mail Address george@res-nc.com
Phone: Office # Mobile # 704-530-8867
9. Landowner(s) of Record (attach accompanied page to list additional owners):
RES-NC Restoration LLC 704-530-8867 704-530-8867
Name Phone: Office # Mobile #
16400 Sutters Run Lane
Current Mailing Address
Huntersville NC 28078
City State Zip
10. Deed Book No. 92 Page No. 55
Current Street Address
City
State
Zip
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
or if the landowner(s) is
an individual(s), the names) of the owner(s) may be listed as the financially responsible partyfts),
RES-NC Restoration LLC
Company Name
16400 Sutters Run Lane
Current Mailing Address
Huntersville NC 28078
City state Zip
Phone: Office# 704-530-8867
george@res-ne.com
E-mail Address
16400 Sutters Run Lane
Current Street Address
Huntersville NC 28078
City State Zip
Mobile# 704-530-8867
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 domesticoompany registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent.
George Fountas george@res-nc.com
Name of Registered Agent E-mail Address
16400 Sutters Run Lane 16400 Sutters Run Lane
Current Mailing Address
Huntersville NC
City State Zip
Phone: Office# 704-530-8867
Current Street Address
28078 Huntersville NC 28078
City
State Zip
Mobile# 704-530,-8867
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 INC Secretary of State business registry:
Name of Registered Agent E-mail Address
Current Mailing Address.
City State Zip
Phone: Office#
Current Street Address
City State Zip
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
(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:
CESI Civil-Geotechnical-Surveying
Engineering firm or other consultant
Nick Buysse, PE
Individual contact person (type or print)
nickbuysse@cesiGgs.com
E-mail Address
704-786-5404 704-902-6169
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 information should there be any change in the information provided herein.
George Fountas
Type or print name
Si ure
Member
Title or Authority
1/17/20
Date
AJ Ck- a Notary Public of the County of
State of North Carolina, hereby certify that, r? to r-q, e, Fext hs appeared personally
before me this day and being duly sworn acknowledg6d that the above form was executed by him/her.
Witness my hand and notarial seal, this _Le) day of .20 93
Notdry
119 0,
My commission expires 9,
/
v_
�%6
"�U -,Ij
Continued from Items 9 & 10 in Part A of the Financial ResponsibilitylOwnership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 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 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
Current Mailing Address
City
Deed Book No._
Landowner 5 of Record:
Phone: Office #
Current Street Address
Mobile *
State Zip City State Zip
Page No. Provide a copy of the most current deed.
Name Phone: Office#
Current Mailing Address Current Street Address
City State Zip
Deed Book No. Page No.
M
City State Zip
Provide a copy of the most current deed.
Continued from Item I in Part B of the Financial R6sponsibilitylOwnership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible patties.
Company 2 Name
E-mail Address
Current Mailing Address Current Street Address
City
Phone: Office#
.State
Zip City
Mobile #
Company 3 Name E-mail Address
Current Mailing Address
Current Street Address
State
Zip
City State Zip City State Zip
Phone: Office # . Mobile A
Company 4 Name
E-mail Address
Current Mailing Address Current Street Address
City $late zip
Phone: Office#
City State Zip
Mobile
Company 5 Name E-mail Address
Current Mailing Address
Current Street. Address
City State Zip City State Zip
Phone: Office# — Mobile #