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HomeMy WebLinkAboutNCC232120_FRO Submitted_20230714 FINANCIAL RESPONSIBILITY/OWNERSHIP FORM SEDIMENTATION POLLUTION CONTROL ACT No person may initiate any land-disturbing activity on one or more acres as covered by the Soil Erosion and Sedimentation Control Ordinance of the City of Greenville(Title 9,Chapter 8)before this form and an acceptable erosion and sedimentation control plan have been completed and approved by the City of Greenville, Engineering Department. (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 Turnbury Trace 2. Location of land-disturbing activity: County Pitt _ City or Township Greenville Highway/Street Smythewyck Dr. Latitude(dedn,ar de9rees)35.56813 Longitude(decm,ar degrees)-77.35491 3. Approximate date land-disturbing activity will commence: August 2023 4. Purpose of development (residential, commercial, industrial, institutional, etc.): residential 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 4.30 acres 6. Amount of fee enclosed: $ 500.00 . The application fee of$100.00 per acre or portion thereof (rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is$900). 7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed C83 No ❑ 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name Scott T. Anderson, P.E. E-mail Address scott@arkconsultinggroup.com Phone: Office# 252-565-1015 Mobile# 9. Landowner(s)of Record (attach accompanied page to list additional owners): The Covenqton Group, Ltd. Name Phone: Office# Mobile# PO Box 3075 Current Mailing Address Current Street Address Greenville NC 27836 City State Zip City State Zip 10. Deed Book No. 194 Page No. 186 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 owners)may be listed as the financially responsible party(ies). Turnbury Trace, LLC dustinO.taftmillsgroup.com Company Name E-mail Address PO Box 566 631 Dickinson Ave. Current Mailing Address Current Street Address Greenville NC 27858 Greenville NC 27834 City State Zip City State Zip Phone: Office# (252) 752-7101 Mobile# (252)916-2691 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. NI"• � MANPS(102— Type or print name Title or Authority �"C_ 5•S.23 Signature Date l�� I, l(i5Tctv11 � l tunncs , a Notary Public of the County of N,OJ' v1A State of North Carolina, hereby certify that Dvt K1 tl,l,i I is 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 '66 day of f\AI,t t j , 20 23 • Notary Seal My commission expires OC('tC(- ()Dri %,PN 1W1(4/'',,' co • �\ 44, C) f )_ �'UB -OO Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple owne►s. 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 Phone: Office# Mobile it 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 Pad B 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 E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office# Mobile# Company 3 Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office# Mobile# Company 4 Name E-mail Address Current Mailing Address Current Street Address City State ZipCityState Zip Phone: Office Il Mobile# Company 5 Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office# Mobile it