HomeMy WebLinkAboutNCC230222_FRO Submitted_20230203Check if this project is ARPA-funded
FINANCIAL 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. including any
activity under a common plan of development of this size as covered by the NCG01 permit, 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.
Project Name Lapps Residence
*If this project involves American Rescue Flan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI),
2. Location of land -disturbing activity: County.
Caldwell
City or Township
Granite Falls
Highway/Street6163 Plantation Point Dr Latitude(derAmal degrees) 35.800 Longitude(decimal degrees)-81.339
3. Approximate date land -disturbing activity will commence: Jan 1. 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.35
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 ❑ Enclosed ® No Ll
8_ Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Justin Morrison E-mail Address infoCoNcmcustomehomes.com
Phone: Office #
Mobile # 828-217-3862
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Joseph Lapps
Name
111 Bunker Hill Ln
Current Mailing Address
610-812-8234
Phone: Office # Mobile #
111 Bunker Hil} Ln
Current Street Address
Statesville NC 28677 Statesville NC 28677
City State Zip City State Zip
10. Deed Book No. 2041 Page No. 1855 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 responsibie party(ies).
Joseph Laops
Company Name
111 Bunker Hill Ln
Current Mailing Address
Statesville NC 28677
City State Zip
Phone: Office #
Ianahuska5amail com
E-mail Address
111 Bunker Hill Ln
Current Street Address
Statesville NC 28677
City State Zip
Mobile # 610-812- 8234
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:
Dan Shabeldeen
Name of Registered Agent
3145 Tate Blvd
Current Mailing Address
Hickory NC 28602
City State Zip
Phone: Office #
danashabeldeen-engineering.com
E-mail Address
3145 Tate Blvd
Current Street Address
City
Mobile # 828-320-7252
Name of Individual to Contact (if Registered Agent is a company)
NC 28602
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
corrected information should there be any change in the information provided herein.
.- or print name
/Si66atGreT7--- l rbe"I f.l•A I/
Owner
Title or Authority
I r'I �a 3
Date
I, a Notary Public of the County of C1W0Vq
V-4 pp5
State of North Carolina, hereby certify that u��� Lnco5 � rnrply n 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 I day of %Tonuoir 20 2'�3
Notary
My commission expires Wq 1202ko
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:
Carolyn Lapps 610-812-8234
Name Phone: Office # Mobile #
111 Bunker Hill Ln 111 Bunker Hill Ln
Current Mailing Address Current Street Address
Statesville NC 28677 Statesville NC 28677
City State Zip City State Zip
Deed Book No. 2441 Page No. 1855 Provide a copy of the most current deed.
Landowner 3 of Record:
Name
Current Mailing Address
City State
Deed Book No.
Landowner 4 of Record:
Name
Current Mailing Address
Phone: Office # Mobile #
Current Street Address
Zip City State Zip
Page No. Provide a copy of the most current deed.
Phone: Office #
Current Street Address
Mobile #
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.