NCC221834_FRO Submitted_20220513

FINANCIAL RESPONSIBILITYIOWNERSHIP 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. (Please type or print and, if the question is
not applicable or the e-mail and/or fax information unavailable, place NIA in the blank.)
Part A.
1. Project Name: Senior Center East
2. Location of land -disturbing activity: County Cumberland City or Township Fayetteville
Highway/Street V1/ashin tan Drive Latitude 35.068094° Longitude-78.892814-
3. Approximate date land -disturbing activity will commence: March 2022
4. Purpose of development (residential, commercial, industrial, institutional. etc.): Recreational
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.25
6. Amount of fee enclosed: $600.00 The application fee of $100,00 per acre (rounded up to the
next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585.00),
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:
Robert5tone@
Name Robert Stone E-mail Address FayettevilleNC.gov
Telephone [phone] Cell # 910-818-8146 Fax #
.11
Landowner(s) of Record (attach accompanied page to list additional owners):
City of Fa etteville 910-433-1000
Name Telephone
433 Hay Street Same
Current Mailing Address Current Street Address
Fayetteville, NC 28301
City State Zip City State Zip —
10. Deed Book No. 10512 Page No. 732 Provide a copy of the most current deed.
Part B.
Fax Number
1. Company (ies) 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.
City of Fayetteville, Doug Hewett, City Mqr_ Doug HewettgFayettevilieNC.gov
Name E-mail Address
433 Hay Street Same
Current Mailing Address Current Street Address
Fayetteville, NC 28301
City State Zip City State Zip
Telephone # [phone] Fax 4

2. (a) If the Financially Responsible Party is not a resident of Borth Carolina, give name and street address
of the designated North Carolina Agent:
NIA
Name
Current Mailing Address
City State Zip
Telephone #
E-mail Address
Current Street Address
City State Zip
Fax #
(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:
NIA
Name of Registered Agent
Current Mailing Address
City State Zip
Telephone #
E-mail Address
Current Street Address
City State zip
Fax #
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 attomey-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.
Dou ewett
Type print name
LctJ
Si nature
-----------
CityManager
Title or Authority
ate
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a Notary Public of the County of
State of North Carolina, hereby certify that appeared personally
Before me this day and being duly sworn acknowledg that the above form was executed by him.
Witness my hand and notarial sea[, this AI tay ❑ 202
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