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Home My WebLink AboutNCC232640_FRO Submitted_20230920 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 address or phone number is unavailable, place N/A in the blank.) Part A. 1. Project Name: Briar/Little Hope Creek Greenway 2. Location of land-disturbing activity: County: Mecklenburg City or Township: Charlotte Highway/Street: 4020 Cranford Dr Latitude(decimal degrees): 35.163326 Longitude(decimal degrees):-80.858839 3. Approximate date land-disturbing activity will commence: Spring 2023—Spring 2024 4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 10.50 acres 6. Amount of fee enclosed: $1,100. 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 ❑ Enclosed DI No ❑ 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name: Robert Billings E-mail Address: Robert.Billings anmecklenburgcountync.gov Phone: Office#: (980)-314-2503 • 9. Landowner(s) of Record (attach accompanied page to list additional owners): MECKLENBURG COUNTY Name Phone: Office# Mobile# 600 E 4' St 11TH FL 600 E 4"h St 11TH FL Current Mailing Address Current Street Address Charlotte NC 28202 Charlotte NC 28202 City State Zip City State Zip 10. Deed Book No. 9276 Page No. 437 Provide a copy of the most current deed. SEE ATTACHED. 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). Mecklenburg County (Contact: Robert Billings) Robert.Billings(cr�mecklenburgcountvnc.gov Company Name E-mail Address 600 E. 4th Street 600 E, 4th Street • • Current Mailing Address Current Street Address Charlotte NC 28202 Charlotte NC 28202 City State Zip City State Zip Phone: Office#(980)-314-2503 Mobile#j980)-314-2503 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: Kimlev-Horn and Associates aiexandra.mcintyre@,kimlev-horn.com • • Name of Registered Agent E-mail Address • • 200 South Tryon Street, Suite 200 Current Mailing Address Current Street Address Charlotte NC 28202 City State Zip City State Zip Phone: Office# 704-636-1192 Mobile# Alex McIntyre 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. *Oil a01104,1) Cd ,T Company DBA Namw / 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 c o ected information should there be any change in the information provided herein. / obarr (3 ;IL'A S Csir4o' ño' eer AlM er Ti pe r print .me Title or Authority J U i?/ft 2 bait Signature Date la- (iüjyis a Notary Public of the County of ilecrienlown State of North Carolina, hereby certify thatcertify tha't--kei9thf Bli If n appeared personally before me this day and being duly sworn acknowledged that the abode form was executed by him/her. Witness my hand and notarial seal, this Joy- day of r- , 20 t c lF V W = yh- f i)-) N a ry Sea; rth 7 My commission expires 1 02_0;2,3 . . ..... ..: ...- .. .,. ., Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple owners. Attach copies of this page as needed to list all landowners. Landowner 2 of Record: MECKLENBURG COUNTY Name Phone: Office# Mobile# 600 E 4th St 11T" FL 600 E 4th St 11T" FL Current Mailing Address Current Street Address Charlotte NC 28202 Charlotte NC 28202 City State Zip City State Zip Deed Book No. 10046 Page No. 422 Provide a copy of the most current deed. Landowner 3 of Record: MECKLENBURG COUNTY Name Phone: Office# Mobile# • 600 E 4th St 11T"FL 600 E 4th St 11TH FL Current Mailing Address Current Street Address • Charlotte NC 28202 Charlotte NC 2820R City State Zip City State Zip Deed Book No. 17737 Page No. 053 Provide a copy of the most current deed. • • Landowner 4 of Record: MECKLENBURG COUNTY • Name Phone: Office# Mobile# • 600 E 4th St 11T" FL 600 E 4th St 11' FL Current Mailing Address Current Street Address • • Charlotte NC 28202 Charlotte NC 28202 City State Zip City State Zip • • Deed Book No. 11020 Page No. 318 Provide a copy of the most current deed. Landowner 5 of Record: MECKLENBURG COUNTY Name Phone: Office# Mobile# 600 E 4" St 11TH FL 600 E 4th St 11T" FL • Current Mailing Address Current Street Address Charlotte NC 28202 Charlotte NC 28202 City State Zip City State Zip Deed Book No. 14587 Page No. 609 Provide a copy of the most current deed. Landowner 6 of Record: MECKLENBURG COUNTY Name Phone: Office# Mobile# • 600 E 4' St 11TH FL 600 E 4'St 11TH FL Current Mailing Address Current Street Address • • Charlotte NC 28202 Charlotte NC 28202 City State Zip City State Zip Deed Book No. 04951 Page Na. 038 Provide a copy of the most current deed. Landowner 7 of Record: MECKLENBURG COUNTY Name Phone: Office# Mobile# 600 E 4tt' St 11' FL 600 E 4th St 11TH FL Current Mailing Address Current Street Address Charlotte NC 28202 Charlotte NC 28202 • City State Zip City State Zip • Deed Book No. 04951 Page No. 033 Provide a copy of the most current deed.