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HomeMy WebLinkAboutNCC240818_FRO Submitted (2)_20240327 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.) P1.art A.Project Name Burke-2024-0112 2. Location of land-disturbing activity: CountyBUrke City or Township Connelly Springs Highway/Street Jumping Run Latitude35.7750 -81 .4600 Longitude 3. Approximate date land-disturbing activity will commence:1 Apr24 4. Purpose of development(residential, commercial, industrial, institutional, etc.):Residential 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):2.73 6. Amount of fee enclosed: $ 300.00 . The application fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount(Example: 8.10 ac= $900.00). 7. Has an erosion and sediment control plan been filed? YesX No Enclosed 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name Tyler Hart E-mail Address thart@ardadesigns.com Telephone 980-429-3057 Cell# 980-429-3057 Fax# 9. Landowner(s)of Record (attach accompanied page to list additional owners): Todd Terrell/Tracilea Young 682-561-4307 Name Telephone Fax Number 406 Gartell Way 406 Gartell Way Current Mailing Address Current Street Address Cary, NC 27519 Cary, NC 27519 City State Zip City State Zip 10. Deed Book No.002522 Page No.000946 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. Debra Palmer (ARDA Designs, LLC) dpalmer@ardadesigns.corn Name E-mail Address 2089 Starboard Ln 2089 Starboard Ln Current Mailing Address Current Street Address Connelly Springs, NC 28612 Connelly Springs, NC 28612 City State Zip City State Zip Telephone704-747-2401 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: Name of Registered Agent E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Telephone 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. Debra L Palmer—, Owner, ARDA Designs, LLC pe oi', r(nt na Title or Authority , lq V '1V_ ,2. Sign re Date I, C In r)34 OPi-2f +,,,, j 4--,S er• , a Notary Public of the County of G e4,11,,bA. State of North Carolina, herebycertifythat ,--r,, 1.-r<cf ��� -. 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 day of rC1-J , 20 ,7 V (/ \\\\1 i%%Ill 11r/0 / NER M �p/,,�� ? Notary Public 'LN Notary Seal Catawba Os. = County Z= My commission expires--)45G�ZC c Trim EV' r 'Q,L nnn