HomeMy WebLinkAboutNCC215586_FRO Submitted_20211008FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007
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 Printcraft
2. Location of land -disturbing activity: County Davidson City or Township Lexington
Highway/Street City Lake Road Latitude 35.867 Longitude-80.247
3. Approximate date land -disturbing activity will commence: Upon Approval
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas). 1.5 acres
6. Amount of fee enclosed. $ 630.00 . The Express Permitting application fee is a dual charge.
The normal fee of $65.00 per acre is assessed without a ceiling amount. In addition, the Express
Permitting supplement is $250.00 per acre up to eight acres, after which the Express Permitting
supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585). NOTE: Both fees are
rounded up to the next whole acre and need to be paid by separate checks to NCDENR.
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 David Bensley E-mail Address davidbensley@printcraftinc.com
Telephone 336-284-2544 Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Printcraft Company, Inc. 336-284-2544
Name
PO Box 477
Current Mailing Address
Lexington, NC
City
27293
State Zip
Telephone
259 City Lake Road
Current Street Address
Lexington NC
City State
Fax Number
27293
Zip
10. Deed Book No. 1 097 Page No. 1 597 _ 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.
Printcraft Company, Inc. davidbensley@printcraftinc.com
Name E-mail Address
PO Box 477 259 City Lake Road
Current Mailing Address
Lexington NC 27293
City State
Telephone 336-284-2544
Current Street Address
Lexington NC 27293
Zip City
Fax Number
State
Zip
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
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any
necessary information regarding the plan and its preparation:
Hugh Creed Associates, Inc., PA hca@hughcreedassociates.com
Engineering Firm or other consultant
E-mail Address
Norris Z. Clayton
336-275-9826
Individual contact person (type or print)
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.
Type or print name
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Signature
Title or Authority
Date
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