HomeMy WebLinkAboutNCC221275_FRO Submitted_20220405FINANCIAL 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: Locust Subdivision Phase II
2. Location of land -disturbing activity: County Stanly City or Township Locust
Highway/Street Elm Street Latitude 35.251 Longitude 80.412
3. Approximate date land -disturbing activity will commence: 2/1/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 43.0
6. Amount of fee enclosed: N/A transfer. The application fee of $100.00 per acre (rounded up to the next acre) is
assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name ti t+1�A i� P r o t E-mail Address Mar r o 11 .(6t%N1
Telephone 76 `I — tO�2-o -737 Cell # AtA P Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
HC Locust Investments LLC 704-805-4801
Name Telephone Fax Number
1616 Cleveland Ave 1616 Cleveland Ave
Current Mailing Address Current Street Address
Charlotte NC 28203 Charlotte NC 28203
City State Zip City State Zip
10. Deed Book No. 1725 Page No. 854 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.
- Q -
Name
r3 &tr0Lt
E-mail Address
Current Mailing Address Current Street Address
t0 NC 3
City State Zip
City
Telephone —70 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
City State Zip
Teleph
E-mail Address
Current Street Address
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:
�T -�po�a+ior� see
Name of Registered Agent
1 (a 0 M i tie_ 1 _r,,kx4— C -c- .! A-- a b 0
Current Mailing Address
;ram C'A
City State Zip
Telephone. R i `(. - La l - `l 13 9
(� Q C.+ G.(I V CV-4-Ok A- e-
E-mail Address 77
Current Street Address
City State Zip
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- k 1 C a"t [ i s 1 % —
Ty print n
Sign ture
Title or Authority
Date
a Notary Public of the County of
C 4-e,4m
State of North Carolina, hereby certify that C�e�►'' C FDOu_+(eL_wolf 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 o� `4 day of f &rtk , 20 Z;L
Rachel Martin Hayes PULIC Notary
�G�d�tbn C uEnty
North Carolina My commission expires _o2 i , a oas
My Commission Expires May 27, 2025