HomeMy WebLinkAboutNCC216919_FRO Submitted_20211214FINANCIAL 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. Fieldcrest Subdivision
1. Project Name
Q
3.
4.
5.
6.
7.
8.
Location of land -disturbing activity: CountyAlamanCe City or Township NA
Highway/Street Thom Rd, Haw River, NC Latitude 35.975548 Longitude—79.278850
Approximate date land -disturbing activity will commence: December 11 2021
Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2
Amount of fee enclosed: $ 1 30.00 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
Has an erosion and sediment control plan been filed? Yes No Enclosed x
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Chad E. Abbott E-mail Address chad@c3designeng.com
Telephone 919-230-0996 Cell # 9 1 9-625-7368 Fax # NA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Cimland, LLC 919-880-6297 NA
Name
2330 Operations Dr.
Telephone Fax Number
2330 Operations Dr.
Current Mailing Address Current Street Address
Durham, NC 27705 Durham, NC 27705
City State
10. Deed Book No. 82
Zip City
Page No. 252
State
Zip
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.
Cimland, LLC Craig.morrison@cimarronhomes.com
Name
2330 Operations Dr
Current Mailing Address
Durham, NC 27705
City State Zip
Telephone 91 9-580-6297
E-mail Address
2330 Operations Dr
Current Street Address
Durham, NC 27705
City State Zip
Fax Number NA
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:
NA NA
Name E-mail Address
NA NA
Current Mailing Address
NA
City State
Telephone NA
Zip
Current Street Address
NA
City State Zip
Fax Number NA
(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:
NA NA
Name of Registered Agent
NA
Current Mailing Address
NA
City State Zip
Telephone NA
E-mail Address
NA
Current Street Address
NA
City State Zip
Fax Number NA
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.
Typ or print na a Title or Authority
2n*re
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1 C�r-p L , G h e- P�I<, , a Notary Public of the County of b ran
State of North Carolina, hereby certify that S, �rgig IV10rr/sor� 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 MVEM bey^ , 20. 2
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Seal
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My commission expires AloV. 2L/ 2d23