HomeMy WebLinkAboutNCC230047_FRO Submitted_20230111FINANCIAL RESPONSIBIUTY/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
{duality 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 Daryl & Pamelo Jo Briggs
2. Location of land -disturbing activity: County Burke City or Township Connelly Springs
Highway/StreeL 1021 Sunset Point Dr LatitudefcLeartal degrees,® 35.774 Longitude, -81.4
3. Approximate date land -disturbing activity will commence: 10I1122
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.73
6. Amount of fee enclosed: $ 400.00 . 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 IN No ❑
tO
0
Person to contact should erosion and sediment control issues arise during land -disturbing activity-,
Name Justin Morrison E-mail Address infoCa)-icmcustomhomes.com
Phone: Office # T_ 828-217-3862 Mobile #
Landowner(s) of Record (attach accompanied page to list additional owners):
_ Daryl Briggs
Name A
2 ` D 1£eth N-#170
Current Mailing Address
Phone: Office #
2830 16th t NE #170
Current Street Address
727-612-13630E
Mobile #
_ Hickory NG 28601 Hickory NC 28601
City State Zip City State Zip
10. Deed Book No. 2501 Page No. 756 Provide a copy of the most current deed.
Continued from Items 9 & 90 in Part A of the Financial ResponsibilitylOwnership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Pamela Jo Briggs 828-217-0630
Name Phone: Once # Mobile #
2830 16th St NE #170 2830 16th St NE #170
Current Mailing Address Current Street Address
Hickory NC 28601 Hickory
City State Zip City State Zip
Deed Book No. 2501 Page No. 756 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.
Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a cornprehensi've 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).
Daryl Briggs briggsdOhotmail.com
Company Name E-mail Address
2830 16th St NE #170 2830 16th St NE #170
Current Mailing Address Current Street Address
Hickory NC 28601 HickorV NC 28601
City State Zip City State Zip
Phone: Office # 828-217-0630 Mobile #
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:
Name of Registered Agent
E-mail Address
Current Mailing Address Current Street Address
City State Zip City
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(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
corrKta f information should there be any change in the information provided herein.
T o rint name Title or AWho-ice.
-� z- ) 2 PY - -a--
Signature
Date
a Notary
-Public of the County of
-1--)C�
State of North Carolina, hereby certify thatg,-L, ofg c, fir, Q s appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this day of C viy Lj-�� 20
r�
Notary
= Dawn M Cioninger
NOTARY PUBLIC My commission
Catawba County, NC
(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.
aP4 "; — I a ao , J r1Q c,
Type or print name j JTitle or Authority
'-p
Signature U 0 0 Date
1,� 1�, W�--, G� �►-� ; n c , a Notary Public of the County of C" "fir w S
State of North Carolina, hereby certify that �n J 6 iSe, �' 2 appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this d1FL' aay of�)-r c-e , 20 3)-�
Dawn M Cloninger Notary
_
NOTARY PUBLIC My commission expires
�°��' Catawba County, NC
(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/nr print name
Signature
Title or Huihority
Date
a Notary Public of the County of
State of North Carolina, hereby certify that 5:5 '�)_ appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this -,,SA--'day of] , c�c w,�c� 20Dwa,
(-ND,44
Dawn M Cloninger
NOTARY PUBLIC
Catawba County, NC
Notary
My commission expires6 `} / a I j �-c> S-