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HomeMy WebLinkAboutNCC230722_FRO Submitted_20230321FINANCIAL 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 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. 1 2 3 Project Name Oyster Creek Landing Location of land -disturbing activity: County Pender City or Township Hampstead Highway/Street Latitude (decimal y Hwy 17/Hoover Road ( decimal degrees) 34.370681 Longltude(decimal degrees) 77.708308 Approximate date land -disturbing activity will commence: 11 /14/2022 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.0 6. Amount of fee enclosed: $ 600.00 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 p No ❑ 8. Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name Mr. Louis Dworsky E-mail Address Idd12486@gmail.com Phone: Office # (919) 606-3100 Mobile # (919) 606-3100 9. Landowner(s) of Record (attach accompanied page to list additional owners): Hampstead Station, LLC (919) 606-3100 Name PO Box 11634 Current Mailing Address Charlotte, NC 28220 City State 10. Deed Book No. 4787 Phone: Office # Mobile # 903 Long Cove Drive Current Street Address Wilmington, NC 28405 Zip City Page No. 2908-2913 State Zip 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). Hampstead Station, LLC Company Name PO Box 11634 Current Mailing Address Charlotte, NC 28220 City State Zip Phone: office # (919) 606-3100 Idd12486@gmail.com E-mail Address 903 Long Cove Drive Current Street Address Wilmington, NC 28405 City State Mobile # (919) 606-3100 Zip 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: Louis Dworsky Name of Registered Agent PO Box 11634 Current Mailing Address Charlotte, NC 28220 1-ILy Idd12486Qa gmail.com E-mail Address 903 Long Cove Drive Current Street Address Wilmington, NC 28405 State Zip City Phone: Office # (919) 606-3100 Mobile # (919) 606-3100 Name of Individual to Contact (if Registered Agent is a company) State Zip (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) (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 exe uments for the Financially Responsible Party). I agree to provide corrected inforSat6n should t re be any change in the information provided herein. Louis D)mlo rsky f Member Type or,4rint name Title or Authority 1n-6-22. Date a Notary Public of the County of w-- State of North Carolina, hereby certify that UVILS. 1W O "S?L.— 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 dC-�) (at-- , 20 a� Notary My commission expires ALMrW SSTHAL Notary Public New Hanover County, North Carolina My Commission Explres April 22, 2t)23 Continued from Items 9 & 10 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. Double Dimension, LLC (256) 536-9587 (919) 606-3100 Name Phone: Office # Mobile # 2324 Pansy Street, SW 2324 Pansy Street, SW Current Mailing Address Huntsville, AL 35801 Current Street Address Huntsville, AL 35801 City State Zip City State Zip Deed Book No. 4792 Page No.1246-1249 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 Current Mailing Address City Deed Book No. Landowner 5 of Record: Name Current Mailing Address City Deed Book No.. Phone: Office # Mobile # Current Street Address State Zip City State Zip Page No. Provide a copy of the most current deed. Phone: Office # Current Street Address State Zip City Page No. Mobile # State Zip Provide a copy of the most current deed. Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties. Attach copies of this page as needed to list all financially responsible parties. NOT APPLICABLE Company 2 Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office # Mobile # Company 3 Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office # Mobile # Company 4 Name Current Mailing Address City Phone: Office # Company 5 Name Current Mailing Address City Phone: Office # E-mail Address Current Street Address State Zip City Mobile # E-mail Address Current Street Address State Zip City State Mobile # State Zip Zip