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HomeMy WebLinkAboutNCC230473_FRO Submitted_20230217FINANCIAL RESPONSIBILITY/OWNERSHIP FORM SEDIMENTATION POLLUTION CONTROL ACT EXPRESS PERMITTING OPTION 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 and/or fax information unavailable, place N/A in the blank.) Part A. 1. Project Name Bryson's Ridge Lots 1-21 2. Location of land -disturbing activity: County Nash City or Township Spring Hope Highway/Street NC 581 Latitude 35.95635 Longitude-78.10752 3. Approximate date land -disturbing activity will commence: January 2023 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 19.93 6. Amount of fee enclosed: $ Previously Paid . The Express Permitting application fee is a dual charge. The normal fee of $65.00 per acre (rounded up to the next acre) is assessed without a ceiling amount. In addition, the Express Permitting supplement is $250.00 per acre up to eight acres, after which the Express Permitting supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585). 7. Has an erosion and sediment control plan been filed? Yes X No Enclosed 8. Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name Kevin Varnell E-mail Address kvarnell(a�,stocksengineering.com Telephone 252-459-8196 Cell # 252-382-0012 Fax # 9. Landowner(s) of Record (attach accompanied page to list additional owners): Axiom Development, LLC Name 3739 National Drive, Suite 105 Current Mailing Address 919-760-0101 Telephone 3739 National Drive, Suite 105 Current Street Address Fax Number Raleigh NC 27612 Raleigh NC 27612 City State Zip City State Zip 10. Deed Book No. 3154 Page No. 174-177 Provide a copy of the most current deed. Part B. 1. Company (ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship, the name of the owner or manager may be listed as the financially responsible party. Starlight Homes North Carolina LLC raymond.rinker@ashtonwoods.com Name E-mail Address 4025 Lake Boone Trail, Suite 200 4025 Lake Boone Trail, Suite 200 Current Mailing Address Current Street Address Raleigh NC 27607 Raleigh NC 27607 City State Zip City State Zip Telephone 919-872-0048 Fax Number 2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address of the designated North Carolina Agent: Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Telephone Fax Number (b) If the Financially Responsible Party is a Partnership or other person engaging in business under an assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible Party is a Corporation, 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 Telephone Fax Number (c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other consultant who can assist in providing any necessary information regarding the plan and its preparation: Engineering Firm or other consultant E-mail Address Individual contact person (type or print) Telephone Fax Number 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 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 Person). I agree to provide corrected information should there be any change in the information provided herein. Raymond Rinker VP of Land Development Type or print name Title or Authority Signatu V Date --------- -------; ---------------------------------------------------------------------------------------------------------------------- Hif� I, a Notary Public of the County of a R �j jState of North Carolina, hereby certify that '1°ilI 1t�� Ai . Lllr," 3`L�� 4s';'1�: ` appeared personally before me this day and being duly sworn ackno ,ledged that thd above form was executed by him. Witness my hand and notarial seal, this day of ��,������� I '�, 20 n Notary SMARY HILL HEROLD NOTARY PUBLIC My commission expires WAKE COUNTY, INC My Commission Expires 9-24-2026 Addendum to FR/O fora Part A, Item 9: Landowner of Record Letter of Consent Axiom Development LLC Landowner of Record Name: Property Tax ID#/PIN: 044084 lots 1-21 Property Address Line 1: 307 N Louisburg Rd, Spring Hope, NC Property Address Line 2: City/State/Zip Code: 35.9564,-78.1072 Spring Hope, North Carolina 27882 Applicant submitting plan - must match the financially responsible party named in Part B Section 1 of the Financial Responsibility/Ownership (FR/O) Form: Starlight Homes North Carolina LLC Statement of Landowner Consent: In accordance with NCGS 113A-54.1(a), I hereby declare that I am the owner or legally authorized representative of the owner of the property described above and provide my consent for the applicant cited above and in Part B of the FR/O form to submit a draft erosion control plan to the State of North Carolina and to conduct the planned land -disturbing activities on the property listed above and in Part A of the FR/O form. Thomas White Manager Type or Print Name Title or Authority Sign Date twhite@pintailofs.com)Gl,�j'�%,_�6I/ Email Telephone Addendum to FR/O form Part A, Item 9: landowner of Record Letter of Consent Axiom Development LLC Landowner of Record Name: Property Tax ID#/PIN: 007494 lots 22-50 Property Address Line 1: 307 N Louisburg Rd, Spring Hope, NC Property Address Line 2: City/State/Zip Code: 35.9564,-78.1072 Spring Hope, North Carolina 27882 Applicant submitting plan - must match the financially responsible party named in Part B Section 1 of the Financial Responsibility/Ownership (FR/0) Form: Starlight Homes North Carolina LLC Statement of Landowner Consent: In accordance with NCGS 113A-54.1(a), I hereby declare that I am the owner or legally authorized representative of the owner of the property described above and provide'my consent for the applicant cited above and in Part B of the FR/O form to submit a draft erosion control plan to the State of North Carolina and to conduct the planned land -disturbing activities on the property listed above and in Part A of the FR/O form. Thomas White Type or Print Name Signature Manager Title or Authority Date twhite@pintailofs.com Email Telephone