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HomeMy WebLinkAboutNCC240358_FRO Submitted_20240214 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 Name5707 Rehobeth Rd LOT 3 2. Location of land-disturbing activity: County Union City or Township waxhaw Highway/Street Rehobeth Rd Latitude 34.89524 Longitude-80.76232 3. Approximate date land-disturbing activity will commence:October 31, 2021 4. Purpose of development(residential, commercial, industrial, institutional, etc.):residential 5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): .29 ac 6. Amount of fee enclosed: $0.00 . 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@pinnaclehonlesusa.net Telephone 7042913150 Cell# Fax# 9. Landowner(s)of Record (attach accompanied page to list additional owners): Pinnacle Homes USA LLC 7042913150 Name Telephone Fax Number 4389 Indian Trail Fairview rd same Current Mailing Address Current Street Address Indian Trail NC 28079 same City State Zip City State Zip 10. Deed Book No.7743 Page No.294 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 4389 Indian Trail Fairview RD same Current Mailing Address Current Street Address Indian Trail NC 28079 same City State Zip City State Zip Telephone 7042913150 Fax Number N/A 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: Benjamin Russell Ben@Pinnaclehomesusa.net Name of Registered Agent E-mail Address 4389 Indian Trail Fairview Rd same Current Mailing Address Current Street Address Indian Trail NC 28079 same City State Zip City State Zip Telephone 7042913150 Fax Number N/A 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 Owner Type or print name Title or Aut ority I I3/20 Z-7 Signature Date Jennifer 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 13th day of October 20 21 N. lsslon ', Notary `111;O° Seal S (��(�, z' NOTARY My: My commission expires — � I - T�'Jty 10, ma y/ •.nary 1 .,° ,,��: v �