HomeMy WebLinkAboutNCC241868_FRO Submitted_20240710 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 Name Macon Middle School
2. Location of land-disturbing activity: County Macon City or Township Franklin
1345 Wells Grove Rd. 35.161850 -83.356020
Highway/Street Latitude Longitude
3. Approximate date land-disturbing activity will commence:6/03/2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.):institutional
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):2.87
6. Amount of fee enclosed: $ 100.00 . 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? Yes NoX Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Todd Gibbs E-mail Address todd.gibbs@maCon.k12.nc.us
Telephone 828-524-3314 Cell# 828-524-3314 Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Macon County 828-349-2022
Name Telephone Fax Number
5 West Main St. 5 West Main St.
Current Mailing Address Current Street Address
Franklin, NC 28734 Franklin, NC 28734
City State Zip City State Zip
10. Deed Book No.T-40 Page No. 1015 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 maybe listed as the financially responsible party.
Macon County Schools todd.gibbs@macon.k12.nc.us
Name E-mail Address
1202 Old Murphy Rd. 1202 Old Murphy Rd.
Current Mailing Address Current Street Address
Franklin, NC 28734 Franklin, NC 28734
City State Zip City State Zip
828-524-3314
Telephone 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.
Todd Gibbs Director of Facilities
Type or print name off Title or Authority
Todd Gib• •gita y slg d by odd Gibbs
Date:2024.06.1314:34:51-04'00' Director of Facilities
Signature Date
I, `JCC11 Q ` I \ 1S , a Notary Public of the County of•
State of North Carolina, hereby certify that Gl1 bbS appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness myh d notarial seal, th•is � �' day of aA nc , 20
as
NoTARy. (8,: Notary
Seal.
O?` My commission expires \
1