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HomeMy WebLinkAboutNCC231162_FRO Submitted_20230421 Check 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 N/A in the blank.) Part A. 1. Project Name Seaside Village `If this project involves American Rescue Plan 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 Brunswick City or Township Sunset Beach Highway/Street Privateer Loop Latitude(decimai degrees) 33.897 Longitude(decimal degrees)-78.492 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):2.27 acres 6. Amount of fee enclosed: $300.00 . 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 El 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name Tripp Nealy E-mail Address trippnealy@gmail.com/tasmith@earthworksgroup.com Phone: Office# Mobile# 843-450-5254 9. Landowner(s)of Record (attach accompanied page to list additional owners): Moss Park Partners II, LLC 843-651-7900 843-450-5254 Name Phone: Office# Mobile# 1905 Main Street Current Mailing Address Current Street Address Conway SC 29526 City State Zip City State Zip 10. Deed Book No.04833 Page No.0031 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). Moss Park Partners II, LLC trippnealy@gmail.com Company Name E-mail Address 1905 Main Street Current Mailing Address Current Street Address Conway SC 29526 City State Zip City State Zip Phone: Office# Mobile# 843-450-5254 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 9 9 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: Coagency Global Inc bconcaildi@cogencyglobal.com Name of Registered Agent E-mail Address 212 South Tryon Street, Suite 1000 Current Mailing Address Current Street Address Charlotte, NC 28281 City State Zip City State Zip Phone: Office# 866-775-0114 Mobile# Bibiann Concaildi 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 execute instruments for the Financially Responsible Party). I agree to provide corrected information should there be any change in the information provided herein. Moss Park Partners II, LLC/Tripp Nealy Member Type or print name ! Title or Authority t Signature`- 4/ Date I, Theresa Miller , a Notary Public of the County of Georgetown South State of D4M4,0 Carolina, hereby certify that \, \) \`; 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 c c -`c , 20 a.. ) "zit- ILL\ N a My commission expires 1 \2 \2023 THERESA ANN MILLER Notary Public-State of South Carolina My Commission Expires January 26,2026 • 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: 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 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 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 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. 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. 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 E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office# Mobile# Company 5 Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office# Mobile# 1025 South Atlantic MOSS PARK PARTNERS II LLC Bank ��„ �„� i Myrtle Beach,SC 29577 P 0 BOX 201 67-826/532 MURRELLS INLET,SC 29576 3/003 0 PAY THE n I C DE $ SOO. 0 ORDER OF I v C N\k.CLQ_ilg-UrNthi.f2d ±o/ DOLLARS . ca MEMO 1117( - SedrC-ras,Cor 1"1 rL I Pici-1 Rev, AUTHORIZED SIGNATURE PRODUCT DLT103 USE WITH 916E3 ENVELOPE Deluxe Corporation 1-800-328-0304 or www.deluxe.com/shop FCBF97 STKDKO7 08/22/2016 19:53 -3-