NCC231861_FRO Submitted_20230616

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007
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 Environment and Natural Resources. (Please type or print and, if
the question is not applicable or the e-mail and/or fax information unavailable, place N/A in the blank.)
Part A.
1. Project Name Dalton Industrial Lot 6 & Lot 7
2. Location of land-disturbing activity: County Davie City or Township
Highway/Street US Hwy 158 Latitude 36.125535 N Longitude -80.657936 W
3. Approximate date land-disturbing activity will commence: November 1, 2019
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2.12 ac
6. Amount of fee enclosed: $ 945.00 . The Express Permitting application fee is a dual charge.
The normal fee of $65.00 per acre is assessed without a ceiling amount. In addition, the Express
Permitting supplement is $250.00 per acre up to eight acres, after which the Express Permitting
supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585). NOTE: Both fees are
rounded up to the next whole acre and need to be paid by separate checks to NCDENR.
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Carl Carney E-mail Address ccarney(�davieconstruction.com
Telephone [phone] Cell # Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
BCM Associates 336) 399-2905
Name Telephone Fax Number
209 Kennen Crest
Current Mailing Address Current Street Address
Mocksville NC 27028
City State Zip City State Zip
10. Deed Book No. 638 Page No. 768 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Carl Carney
Name E-mail Address
209 Kennen Crest
Current Mailing Address Current Street Address
Mocksville NC 27028
City State Zip City State Zip
Telephone [phone] Fax Number

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Carl Carney ccarneydavieconstruction.com
Name of Registered Agent E-mail Address
152 E Kinderton Way Suite 200
Current Mailing Address Current Street Address
Advance NC 27006
City State Zip City State Zip
Telephone [phone] Fax Number
(c) In 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:
MGES, PLLC mqunnell(a�triad.rr.com
Engineering Firm or other consultant E-mail Address
Michael Gunnell [phone]
Individual contact person (type or print) Telephone Fax Number
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 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 Person). I agree to provide corrected information should there be
any change in the information provided herein.
&At._ ti t r)
Type or prin ame Title or Authority
0C1231�
Signa u Date
I, i\[ rip, t jdRk , a Notary Public of the County of cD j4 t.
State of North Carolina, hereby certify that bit,/ U, 0,41tNfa4 appeared personally
before me this day and being duly sworn acknowledged that the Awe form was executed by him.
Witness my hand and notarial seal, this 1.--
3rd day of 0(Mo e. , 20 tcl
NTAR YORK (1u►Ag 44e /NOYpTAR Pi18LfC ""'
YADKiN COUNTY Notary
NORTH CAROLING �n
Seal my commission Expuea May 22.2023 �v 2
My commission expires f"vt,Av 22
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