Loading...
HomeMy WebLinkAboutNCC232834_FRO Submitted_20230919 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 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 and/ or fax information unavailable, place N/A in the blank.) Part A.1. Project NameStanfield Valley Lots 24, 25 2. Location of land-disturbing activity: County Stanly City or Township Stanfield Highway/Street River Road Latitude 35.224116 Longitude-80.457217 3. Approximate date land-disturbing activity will commence:7/15/2023 4. Purpose of development(residential, commercial, industrial, institutional, etc.):residential 5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 1 6. Amount of fee enclosed: $ 100.00 . The application fee of$65.00 per acre (rounded up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is$585). 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 Ben Russell E-mail Address ben@pinnaclehomesusa.net Telephone 704-291-3150 Cell# Fax# 9. Landowner(s)of Record (attach accompanied page to list additional owners): Elmer Reece Gibson 704-533-2461 Name Telephone Fax Number 4512 River Rd same Current Mailing Address Current Street Address Stanfield NC 28163 same City State Zip City State Zip 10. Deed Book No. 1741 Page No. 1602 Provide a copy of the most current deed. Part B. 1. Company(ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a comprehensive list of all responsible parties on an attached sheet.)If the company or firm is a sole proprietorship, the name of the owner or manager may be listed as the financially responsible party. Pinnacle Homes USA LLC ben@pinnaclehomesUSA.net Name E-mail Address 2908 Morgan Mill Road same Current Mailing Address Current Street Address Monroe NC 28110 same City State Zip City State Zip Telephone 704-291-3150 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: Ben Russell Ben@Pinnaclehomesusa.net Name of Registered Agent E-mail Address 2908 Morgan Mill Road same Current Mailing Address Current Street Address Monroe NC 28110 same City State Zip City State Zip Telephone 7042913150 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. Ben Russell Manager Ty e or print name Ty or Authority �� 6-1-2023 ignature Date Jennifer N. Trull , a Notary Public of the County of Union State of North Carolina, hereby certify that Ben Russell appeared personally before me this day and being duly sworn acknowledged that the above form was executed by him. Witness my hand and notarial seal, this 1 day of June 20 2023 ,� ,, --� oo \FER N• i °.,• 4 [ �� .��� issio� G Not ry �1 NOTARY M My commission expires 1-11-2026 PuBLtO+ o /coU°, , ,,,,,