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HomeMy WebLinkAboutNCC230204_FRO Submitted_20230124FINANCIAL 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. 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. Batty Plumbing 1. Project Name Davidson Thomasville 2. Location of land -disturbing activity: County City or Township Kendall Mill Road 35.851770-80.096420 Highway/Street Latitude(d k,,,,, ,1 Longitudew,a,, ,, November 30,2022 3. Approximate date land -disturbing activity will commence: Commercial 4. Purpose of development (residential, commercial, industrial, institutional, etc.):' 3.72 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 400.00 6. Amount of fee enclosed: $ 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: Brian Deweese bdeweese1972@gmaii.com Name E-mail Address 336-345-1518 Phone: Office # Mobile # 9. Landowner(s) of Record (attach accompanied page to list additional owners): MC Investments of Thomasville, LLC 336-345-1518 Name .210 Gleason Lane Current Mailing Address Thomasville, NC 27360 City State Zip 2523 Phone: Office # Mobile # Current Street Address City State Zip 288 10. Deed Book No. Page No. Provide a copy of the most current deed. t Part B. 1. Company(ies) who are financially responsible for the Iand-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 owners) may be listed as the financially responsible party(les). Brain Deweese MC Investments of Thomasville, Inc. tdbaityplumbing@gmail.com Company Name E-mail Address 210 Gleason Lane Current Mailing Address Current Street Address Thomasville, NC 27360 City State Zip City State Zip 336-345-1518 Phone: Office # 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 State Zip Phone: Office # Mobile # Name of Individual to Contact (if Registered Agent is a company) r (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 DI3A 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). agree to provide corrected information should there be any change in the information provided herein. Brian Deweese Type or print name Signature Owner Fitle or Authority Date I, a Notary Public of the County of fAstin -_-_________ State of North Carolina, hereby certify that .!� appeared personally before me this day and being duly swam acknow edged that the above form was executed by him/her. Witness my hand and notarial seal, this _day of_ e—ejMbpl �t 2022. gANNANotaryM commission expireY