HomeMy WebLinkAboutNCC223742_FRO Submitted (2)_20221103FINANCIAL 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 NIA in the blank.)
Part A.
Trail Ridge Phase 1 -- 8 Lots
1. Project Name.
Forsyth Kernersville
2. Location of land -disturbing activity: County City or Township
County Line Rd.
Highway/Street SR1307 Latitude(decimaidegrees) 36.1343 Long itude(dedmaidegrees)80.0403
3. Approximate date land -disturbing activity will commence: October 15, 2022
residential
4. Purpose of development (residential, commercial, industrial, institutional, etc.):
4.0
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
400.00
6. Amount of fee enclosed: $ 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 ® No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
X Scott Smith ScottSmith@hhhomes.com
Name E-mail Address
336-802-1340
Phone: Office #
Mobile #
336-508-1410
9. Landowner(s) of Record (attach accompanied page to list additional owners):
H&H Constructors Of Fayetteville, LLC 336-802-1340
Name
Phone: Office # Mobile #
2411 Robeson St Ste 200 2411 Robeson St Ste 200
Current Mailing Address Current Street Address
Fayetteville NC 28305 Fayetteville INC 28305
City State
3713
�i0 z^e1: 0 0 Moro]
Zip City
3952
Page No.
State
WE
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 narne(s) of the owner(s) may be listed as the financially responsible party(ies).
H&H Constructors Of Fayetteville, LLC ScottSmith@HHHomes.com
Company Name E-mail Address
2411 Robeson St Ste 200 2411 Robeson St Ste 200
Current Mailing Address
Fayetteville NC
City State
336-802-1340
Phone: Office #
Current Street Address
28305 Fayetteville NC 28306
Zip City State Zip
336-508-1410
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:
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. -
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.
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.
Scott Smith
Type or print name
Title or Authority
Signature Date
---------------------------------------------------------------------------
1, , a Notary Public of the County of
State of North Carolina, hereby certify that 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 day of , 2022.
Notary
Seal
My commission expires
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:
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 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 #
Current Mailing Address Current Street Address
City State Zip City
Deed Book No. Page No.
Landowner 5 of Record:
Name
Current Mailing Address
City State
Deed Book No.
Mobile #
State Zip
Provide a copy of the most current deed.
Phone: Office #
Current Street Address
Mobile #
Zip City State Zip
Page No. Provide a copy of the most current deed.
Continued from Item 9 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name
Current Mailing Address
City State
Phone: Office #
Company 3 Name
E-mail Address
Current Street Address
Zip City State Zip
Mobile #
E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 5 Name
Current Mailing Address
City State
Phone: Office #
E-mail Address
Current Street Address
Zip City State
Zip
Mobile #