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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