HomeMy WebLinkAboutNCC230549_FRO Submitted_20230302FINANCIAL 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 address
or phone number is unavailable, place N/A in the blank.)
Part A.
Project Name Winder Station - Lots 15 & 20
2. Location of land -disturbing activity: County Moore City or Township McNeill Township
Highway/Street Conductor Court Latitude(decimaidegrees) N 35,2503' Long itude(decimal degrees) W-79.2810'
3. Approximate date land -disturbing activity will commence: February 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas)
0.23 Acres
6. Amount of fee enclosed 100.00(Normal) + 250.00(Express) . The Express Permitting application fee is
a dual charge. The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a
ceiling amount. In addition, the Express Permitting supplement is $250 per acre up to eight acres,
after which the Express Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre
application fee is $2,900). Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Leslie Groves E-mail Address leslie.groves(a�dreamfindershomes.com
Phone: Office # 910-486-4864 Mobile #
Landowner(s) of Record (attach accompanied page to list additional owners):
H&H Constructors of Fayetteville LLC
Name
2919 Breezewood Avenue Suite 400
Current Mailing Address
910-486-4864
Phone: Office # Mobile #
Same
Current Street Address
Fayetteville NC 28303 Same
City State Zip City State Zip
Lot 15 Lot 20 Lot 15 Lot 20
10. Deed Book No. 5928 5971 Page No. 311 245 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 responsible party(ies).
Dream Finders Homes LLC
Company Name
3709 Raeford Road Suite 200
Current Mailing Address
Fayetteville NC 28304
City State Zip
Phone: Office # 910-486-4864
leslie.groves(a)-dreamfindershomes.com
E-mail Address
Same
Current Street Address
Same
City State Zip
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
Current Mailing Address
E-mail 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
(d) If 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. -
Moorman, Kizer & Reitzel Inc.
Engineering firm or other consultant
Dennis A. Gilbert
Individual contact person (type or print)
dgilbert(o)mkrinc.com
E-mail Address
910-484-5191
Phone: Office #
Mobile #
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.
Leslie Groves
Type or print name
Siahature
Division President
Title or Authority
(7
Date
6ree J a Notary Public of the County of
State of North Carolina, hereby certify that
personally before me this day and being duly swor
executed by him/her.
Witness my hand and notarial seal, this "\ day of
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