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HomeMy WebLinkAboutNCC223936_FRO Submitted_20221123FINANCIAL 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 address or phone number is unavailable, place N/A in the blank.) Part A. 1. Project Name Northside Estates 2. Location of land -disturbing activity: County Madison City or Township Mars Hill Highway/Street US Hwy 19 Latitude(d ,;852054 Longitude(d 4)i7eFees 3. Approximate date land -disturbing activity will commence: July 2022 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.0 ac 6. Amount of fee enclosed: $ 300.00 . 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 ❑ Enclosed ® No ❑ 8. Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name Frank Rogers E-mail Address frank.rogers@daytonhomes.com Phone: Office # Mobile # 828-215-1261 9. Landowner(s) of Record (attach accompanied page to list additional owners): CMH Homes, Inc Name Phone: Office # 5000 Clayton Rd Current Mailing Address Maryville, TN 37804 City State Zip Current Street Address Mobile # City State Zip 10. Deed Book No. 752 Page No. 212 Provide a copy of the most current deed. (c) If the Financially Responsible Parry 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. C. 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. f 'ram •� t� Pew, Q-rs ` Type or print name Title or Authority L -7 - z Z- Signature Date CT Cclrve5 a Notary Public of the County of lA me State of North Carolina, hereby certify that V-G(rU4- k04R&L appeared personally before me this day and being duly swom ack n owledged that th bove form was executed by him/her. Witness my hand and notarial seal, this ~ day of , 20 ata `,````;DAIIiA��N4y'yy `_ ,7 �L4 aLu QCIC� NQTARI- R1s Notaty My commission expires o, 0— 20ZZ 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(res). CMH Homes, Inc Company Name 1123 Smokey Park Hwy Current Mailing Address frank.rogers@claytonhomes.com E-mail Address 1123 Smokey Park Hwy Current Street Address Candler, NC 28715 Candler, NC 28715 City State Zip City State Zip Phone: Office # Mobile # 828-215-1261 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 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) (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: CT Corporation System Name of Registered Agent E-mail Address 160 Mine Lake Ct, Ste 200 Current Mailing Address Current Street Address Raleigh, NC 27615 City State Zip City State Zip Phone: Office # 919-944-4780 Mobile # Name of Individual to Contact (if Registered Agent is a company) Continued from Items 9 & 10 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: 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 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 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. Continued from Item 1 in Part B 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 Current Mailing Address E-mail Address Current Street Address City State Zip City State Zip Phone: Office # Mobile # Company 3 Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office # Mobile # Company 4 Name E-mail Address Current Mailing Address Current Street Address City State Zip Phone: Office # City State Zip Mobile # Company 5 Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office # Mobile # Carolinas Engineering and Development, PA 11 Duke Street Asheville, NC 28803 MikeTAndersonPE(Mizmail.com 828-582-8970 May 18, 2022 To Whom it May Concern Re: North Side Estates I, the current landowner/managing partner of the property identified below, hereby authorize Carolinas Engineering and Development, PA (CED) to act on my behalf as my agent during the processing of permits to impact Wetlands and Water of the US subject to Federal jurisdiction under Section 404 of the Clean Water Act and/or apply for Land Disturbance Permits through NCDEQ. Additionally, I authorize representatives of the Wilmington District, US Army Corps of Engineers, and representatives of NCDEQ to enter upon the property herein described for the purposes of conducting onsite investigations associated with the permits requested. Property Owner of Record CMH Homes. Inc Property Owner Address 1123 Smokev Park Hwy. Candler, NC Phone Number (828) 215-1261 Email Address frank.roQers@claytonhomes.com Property Location US Hwy 19 Madison Countv 35.852054. -BM91407 Owner/Managing Partner Signature Owner/Managing Partner Name DateZ-- 828-582-8970 11 Duke St. Asheville, NC 28803 MikeTAndersonPEOW¢mail.eom NC Firm C-4902 Page 1 of 1