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HomeMy WebLinkAboutNCC220830_FRO Submitted_20220303FINANCIAL 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. 1. Project Name The Villas at Shingletree 2. Location of land -disturbing activity: County Brunswick City or Township Carolina Shores Highway/street Shingletree Rd Latitude 33.92234 N Longitude 78.58145 W 3. Approximate date land -disturbing activity will commence: 4 1 /1 /2022 Purpose of development (residential, commercial, industrial, institutional, etc.): Residential 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 21.14 6. Amount of fee enclosed: $ 100 . 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). 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 Sammy Gay E-mail Addresssammygay@sccoast.net Telephone 843-347-5851 cell # 843-457-4051 Fax # 843-347-2792 9. Landowner(s) of Record (attach accompanied page to list additional owners): RRCAP FA Shingletree, LLC 980-223-6026 843-347-2792 Name Telephone Fax Number 517 Alcove Rd Ste 301 517 Alcove Rd Ste 301 Current Mailing Address Current Street Address Mooresville, NC 28117 Mooresville, NC 28117 City State Zip City State Zip 10. Deed Book No. 04614 Page No. 0918 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. RRCAP FA Shingletree, LLC jmosley@riverrcap.com Name E-mail Address 517 Alcove Rd Ste 301 517 Alcove Rd Ste 301 Current Mailing Address Current Street Address Mooresville, NC 28117 Mooresville, NC 28117 City State Telephone 980-223-6026 Zip City State Zip Fax Number 843-347-2792 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: n/a Name Current Mailing Address City Telephone E-mail Address Current Street Address State Zip City State Zip 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: Jerry Mosley jmosley@riverrcap.com Name of Registered Agent E-mail Address 517 Alcove Rd Ste 301 517 Alcove Rd Ste 301 Current Mailing Address Mooresville, NC 28117 City State Zip Telephone 980-223-6026 Current Street Address Mooresville, NC 28117 City State Zip Fax Number 843-347-2792 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. Jerry Mosley Owner Type of -I t na ' 11, Ggn . re ----=-------- ------- State of North Ca personally before executed by him. Title or Authority JO Ve w 6,/Y J0►Z02-I Date a Notary Public of the County of rolina, hereby certify that W-C4 moS f e appeared me this day and being duly s rn acknowle ed that the above form was Witness my hand and notarial seal, this ay of dMW►1t/V 20 WIN ��Go�missio;�,''�!�O � Notary S*9IFA - _ 'OUat_tc U My commission expires "f bo2 Cy, jRG C ' O� "`