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HomeMy WebLinkAboutNCC220620_FRO Submitted_20220209FINANCIAL 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. Sp encer s Woods S/D ESC Plan 1. Project Name 2. Location of land -disturbing activity: County_Edgecombe City or Township Tarboro Highwayistreet Spencer Drive _Latitude 35.876506 Longitude -77.581679 3. Approximate date land -disturbing activity will commence: November 2021 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 32.9 Acres 6. Amount of fee enclosed. S$2,000+2,145 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 Barton Horne E-mail Address barton a@ionesandsmith.us Telephone 252-746-7628 _ cell # 252-746-7628 Fax # 9. Landowner(s) of Record (attach accompanied page to list additional owners): *See Attached Big Time Grand, LLC . 252-903-9889 ' Name Telephone Fax Number 4460 Meadowbrook Rd. 4460 Meadowbrook Rd. Current Mailing Address Current Street Address High Point NC 27265 Rocky Mount NC 27801 City State Zip City State Zip *See Attached 10. Deed Book No. 1738 -Page No. 1013 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. Big Time Grand, LLC bigtimegrand@gmail.com Name E-mail Address 4460 Meadowbrook Rd. 4460 Meadowbrook Rd. Current Mailing Address Current Street Address Rocky Mount NC 27801 Rocky Mount NC 27801 City State Telephone 252-903-9889 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 Current Mailing Address E-mail Address Current Street Address City State Zip City Telephone Fax Number State Zip (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 Current Mailing Address City Telephone E-mail Address Current Street Address State Zip City State Zip 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: Appian Consulting Engineers, P.A. drevoir@appianengineers.com Engineering Firm or other consultant E-mail Address David Revoir 252-972-7703 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. C.B. Daughtridge Managing Member Ty e or pr na a Title or Authority t A I Signature Da e ------------------- ------- -----------------._._---------------------------------------------------------- a Notary Public of the County of V r` r State of North Carolina, hereby certify that I w>ti%r�� appeared personally before me this day and being duly sworn acknowledged that the a0ve form Qs executed by him. Witness my hand and notarial seal, this day of �FA EDWARDS NELMS j NOTARY PUBLIC NASH COUNTY, NC My Commission Expires 11-30-2025 , 20a\ My commission expires 1\ - - aoa 5