HomeMy WebLinkAboutNCC222622_FRO Submitted_20220725FINANCIAL 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.G. 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 address or phone
number is unavailable, place NIA in the blank.)
Part A.
1. Project Name Rocky Ridge Subdivision
2. Location of land -disturbing activity: County range City or Township
Highway/Street G&B Lane Latltude(decimal degrees) 35,9821 Longitude(decimal degrees) -79.1327
3. Approximate date land -disturbing activity will commence: Summer 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.57
6. Amount of fee enclosed: $ 200.00 . 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).
Checks should be addressed to NCDEQ.
7, Has an erosion and sediment control plan been filed? Yes 1@ Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name William Wirt E-mail Address william.Wirt G@summitde.com
Phone: Office # 919-732-3883 Mobile # 757-621-5482
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Bryan T. Evans 919-360-9671 919-360-9671
Name
2509 Viburnum Court
Current Mailing Address
Charlotte, NC 28215
City State Zip
10. Deed Book No. 6713 page No.
Phone: Office # Mobile #
2509 Viburnum Court
Current Street Address
Charlotte, NC 28215
City
443
State
Zip
Provide a copy of the most current deed.
Part B.
1 _ Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) if the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
EVANS ESTATES RE] LLC
Company Name
2509 Viburnum Court
Current Mailing Address
Charlotte, NC 28215
City State Zip
Phone: Office # 919-360-9671
byantabithaevens@gmail.com
E-mail Address
2509 Viburnum Court
Current Street Address
Charlotte, NC 28215
City State Zip
Mobile # 919-360-9671
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Name of Registered Agent
Current Mailing Address
City State
Phone: Office #
E-mail Address
Current Street Address
Zip City
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent
E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Type or print name
at
.Pyes d
Title or Authority
U1 la 2-
Date ^
I, a Notary Public of the County of f In bi .V
State of North Carolina, hereby certify thatEy i I'rt. vvn% LlyavK IiOb'Ww; C)QrtrnS%eared personally
before me this day and being duly sworn acknowledged that the bbove form was executed by hire/her.
Witness my hand and notarial seal, this 2T `day of Jutnf- , 20
Notary
�. My commission expires
oZ
Continued from Items 9 & 90 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Tabitha D. Evans
919-360-9671 919-360-9671
Name
Phone: Office # Mobile #
2509 Viburnum Court
2509 Viburnum Court
Current Mailing Address
Current Street Address
Charlotte, NC 28215
Charlotte, NC 28215
City State
Zip
City State Zip
Deed Book No. 6713
page No 443 Provide a copy of the most current deed.
Landowner 3 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 4 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 5 of Record
Name
Current Mailing Address
City State
Deed Book No.
Phone: Office # Mobile #
Current Street Address
Zip City State Zip
Page No. Provide a copy of the most current deed.
Continued from Item 9 in Part 8 of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name
E-mail Address
Current Street Address
Current Mailing Address
Zip City State Zip
City State
Phone_ Office #
Mobile #
E-mail Address
Company 3 Name
Current Street Address
Current Mailing Address
Zip City State Zip
City State
Phone: Office #
Mobile #
E-mail Address
Company 4 Name
Current Street Address
Current Mailing Address
Zip City State Zip
City State
Phone: Office #
Mobile #
Company 5 Name
Current Mailing Address
City
Phone: Office #
E-mail Address
Current Street Address
State Zip City State
Mobile #
Zip