HomeMy WebLinkAboutNCC230659_FRO Submitted_20230313FINANCIAL 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 Country Club Dr._ Culvert Replacement (COC Project #: 2021-043
2. Location of land -disturbing activity: County Cabarrus City or Township Concord
Highway/Street Country Club Dr Latitude 35.444062 Longitude-80.603877
3. Approximate date land -disturbing activity will commence: Mar 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Municipal infrastructure
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.64
nr
6. Amount of fee enclosed: $ n/a . 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 ❑x Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name ALOX Oyu_ E-mail Address Ar-CX c-qt-��A5iTZtA®'�S )A. co"
Phone: Office # Jo'-1- �5 S - -7493 Mobile # 70'4-
9. Landowner(s) of Record (attach accompanied page to list additional owners):
City of Concord (704) 920-5555
Name Phone: Office # Mobile #
PO Box 308 35 Cabarrus Ave. W
Current Mailing Address Current Street Address
Concord NC 28026-0308 Concord NC 28025
City State Zip City State Zip
10. Deed Book No. n/a Page No._n/a 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).
Carolina Siteworks Inc. darrell(a)carolinasiteworks.com
Company Name E-mail Address
PO Box 280 300 Wade Drive
Current Mailing Address Current Street Address
China Grove NC 28023 China Grove NC 28023
City State Zip City State Zip
Phone: Office # (704) 855-7438 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 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:
n/a
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
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.
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Type or print name' ® Title or Authority
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Signature Date
I, CVyi S-h, m '?-,, AAt � a Notary Public of the County of 7\0u:o .J
State of North Carolina, hereby certify that T. V6 ° sk'\e' A' 0 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 day of % AQ--1 -, , 20�_
Notary
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