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HomeMy WebLinkAboutNCC240699_FRO Submitted_20240313 Check if this project is ARPA-funded ❑ Attach a copy of the Letter of Intent to Fund 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, including any activity under a common plan of development of this size as covered by the NCGO1 permit, 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 Brayden at Bermuda Run, Phase 2B *If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name or Project Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the Division of Water Infrastructure (DWI). 2. Location of land-disturbing activity: County Davie City or Township Bermuda Run Highway/Street Morning Star Drive Latitude(decimal degrees) 36.019 Longitude(decimal degrees) -80.452 3. Approximate date land-disturbing activity will commence: January 2023 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 14.75 Ac. 6. Amount of fee enclosed: $ 1,500.00 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 IINC No ❑ 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name Chandler Turpin E-mail Address cturpin@mungo.com Phone: Office# Mobile# (336)462-1070 9. Landowner(s)of Record (attach accompanied page to list additional owners): Clayton Properties Group, Inc. (DBA Shugart Homes, Inc.) (336)765-9661 Name Phone: Office# Mobile# 221 Jonestown Road 5000 Clayton Road Current Mailing Address Current Street Address Winston-Salem NC 27104 Maryville TN 37804 City State Zip City State Zip 10 Deed Book No. 1118 Page No. 441 &444 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 owner(s) may be listed as the financially responsible party(ies). Clayton Properties Group, Inc. (DBA Shugart Homes, Inc.) cturpin@mungo.com Company Name E-mail Address 221 Jonestown Road 5000 Clayton Road Current Mailing Address Current Street Address Winston-Salem NC 27104 Maryville TN 37804 City State Zip City State Zip Phone: Office# (336) 765-9661 Mobile# 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: CT Corporation System Name of Registered Agent E-mail Address 2700 Lake Cook Rd. 160 Mine Lake Ct., Ste. 200 Current Mailing Address Current Street Address Riverwoods, IL 60015 Raleigh, NC 27615 City State Zip City State Zip Phone: Office# (212) 894 8940 Mobile# J. Michele Balnius,Vice President 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. (DBA Shugart Homes) 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. Chandler Turpin Land Development manager Type or print name Title or Authority /2//2%rl 2-3 Signature Date I, H,mb..eA Z. /*hal:5 , a Notary Public of the County of rekSgHl State of North Carolina, hereby certify that Na/tin 1V r7I 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 )2 day of , 20 23 Notary KIMBERLY L NICHOLS �a , /9 ..2 Qd 7 NOTARY PUBLIC My commission expires FORSYTH COUNTY STATE OF NORTH CAROLINA 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: Wilburn P. Walker Name Phone: Office# Mobile# 3643 Hege Street Current Mailing Address Current Street Address Winston-Salem NC 27127 City State Zip City State Zip Deed Book No. 324 Page No. 636 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# 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