NCC217113_FRO Submitted_20211222

City of Henderson For City Use Only
Engineering Department FrotmReceived:
Post Office Box 1434.900 S. Beckford Dr.
o e CA Henderson, NC 27536-1434
Phone: [phone] / Fax: [phone]
FINANCIAL RESPONSIBILITY/OWNERSHIIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity covered by the Act before this form has been
completed and filed with the appropriate Office of the City of Henderson, Engineering Department,
Attn: Clark Thomas, Director of Engineering. Please make payable the appropriate fee that must
accompany submission of this form to "City of Henderson."
Part A
1. Name of Project: The Landings of Henderson
2. Location of land disturbing activity: Latitude: 36.337845 Longitude: 78.426096
(Highway/Street/Address) 105 Parkview Dr. E, Henderson, NC 27536
3. Approximate date land disturbing activity will commence: Sept 1 st, 2021
4. Purpose of activity (residential, commercial, industrial, etc.): Residential
5. Amount of acreage of land to be disturbed or uncovered: 16 Ac.
Plan Review Fee* $125+(20)*6 =$245
Permit Inspection Fee $325+$120=$445
0.50 acre to 0.999 acre = $75.00
1 to 3 acres = $100.00
More than 3 acres = $125.00 + 20.00 per acre
0.50 acre to 0.999 acre = $125.00
1 to 3 acres = $225.00
More than 3 acres = $325.00 + 20.00 per acre
6_ Amount of fee enclosed (plan review + permit inspection): $ 690.00
7. Has an Erosion & Sedimentation Control plan been filed? Yes (❑) No (❑) Enclosed (0)
S. Person to contact or send cop of inspection reports during construction who is responsible for
implementation of measures:
Contact Name: Dave Richardson Phone No.: 910-776-4641
Email: [e-mail] Cell No.: 910-580-6744
9. Land Owner(s) of Record (use blank oaae to list additional owners):
Owner 1
Owner 2
Name
Vance Propco LLC
Current Mailing Address
400 Second Ave NW
City/State/ZipCitylStatelZip Code
Hickory, NC 28601
Telephone No.
910-776-4641
Email Address
[e-mail]
10. Indicate County, Book, and Page where deed or instrument is filed and attach a copy of the deed to this
form (use blank page to list additional deeds or instruments):
County Vance
County
Book 1383
Book
Page 583
Page
Rev. 08/ 18

*The application fee for a single family residence with a lot 7 acre or more disturbed is $100.00
Part B
1. Person(s) or Firm(s) financially responsible for this land-disturbina activity:
Person/Firm
Person/Firm
Name
Carolina Commercial Contractors, LLC
Current Wfing Address
1600 Colon Rd
Ci lState t Code
Sanford, NC 27330
-Telephone No.
910-580-6744
Email Address
[e-mail]
2. Registered Agent, if any, for the person or firm financially responsible:
3
Name
W. Carter Keller
Current MaM62g Address
1600 Colon Rd
City/State Code
Sanford, NC 27330
Telephone No.
919-580-6744
Email Address
[e-mail]
The above information is true and correct to the best of my knowledge and belief and was provided by me
while under oath. (This form must be signed by the financially responsible person if an individual and by
an officer, director, partner, attorney -in -fact, or other person with authority to execute instruments for the
financially responsible per
Signature
Printed Name
Title or Authority
Date
W. Carker Keller
Manager
Zni
I, .A Notr P I"c of the County of , State of North Carolina,
hereby certify that ,V personally before me this day and under oath
acknowledge that the above form was ex utqo by him.
Witness my hand and notarial seal, this day of , 20?,L .
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Rev. 08/18