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Home My WebLink AboutNCC233400_FRO Submitted_20231115 Check if this project is ARPA-funded ❑ Attach a copy of the Letter of Intent to Fund FINANCIAL RESPONSIBILITY/OWNERSHIP FORM SEDIMENTATION POLLUTION CONTROL ACTOCT�� No person may initiate any land-disturbing activity on one or more acres as covered by Act, nnclOdIn i y activity under a common plan of development of this size as covered by the NCG01 p 'Lbefore this form and an acceptable erosion and sedimentation control plan have been completed and approve- Land_ Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the appro priafe 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. r'` ',�,, ,n/( InI r 1. Project Name V lt4tYwn e}rh( it - V V od1mi Lo+ S `If this project involves American Rescue Plan Act(ARPA) funds, list the Project Name or Project Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the Division of Water Infrastructure (DWI). 2. Location of land-disturbing activity: County O1 is I ow City or Township I l �'d, -e 3g• `f62Z - 71,Township. / 97 9 Highway/Street\kw-1rasi S+. Latitude(decimal degrees) LOngltude(decimal degrees) 3. Approximate date land-disturbing activity will commence: (( II i 2,3 4. Purpose of development (residential, commercial, industrial, institutional, etc.): PAW I ottr.1-1 a-I 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): . 2-/ 6. Amount of fee enclosed: $ /04, D 0 . 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 X Enclosed No ❑ 8. Person to contact should erosion and sediment control issues arise during land-disturbing a ctivity: Name ( hric g rd E-mail Address C 64 al ( Wi �.d4041(W f•UJ Phone: Office# n Q Mobile# gm - 1Q Z i - U-3 5 2 9. Landowner(s) of Record (attach accompanied page to list additional owners): Ulf 4im- I11 4Im-.nfh, L 3310- 21'2 -36-35 wo-7'/2- 7/37 Name Phone: Office# Mobile# P186% i7&"Y 1601 /fr4rind Ay f iU 30 l Current Mailing Address Current Street Addres 0eI VI"WIN 2 tIO/ eiranfbra NC 214o1 City J State Zip City State Zip 10. Deed Book No. (10 Zq Page No. Lou 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). Oincisdy InreAr efiff, LUC, & oLcere wind fir hwed. w Company Name E-mti'll Address M, /DG 7 &4Jt9qr6uM.dk fitYc3 / Current Mailing Address Current Street Addres w� Irwv h i th Z fbI Cree b NC 21/ot' City State Zip City ' State Zip Phone: Office# 33t,— 2d�j 2 — 353� Mobile# q,Q -7//2- 7/;7 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: 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. I n dJ 11r HiwitJ 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. Tara 61r-er Covwanq 41i'il- Typ- .r print name Title or Authority — / /1)/Z 3/2e z Signature Date I, 1 l LL` &h(1P.(d J[ , a Notary Public of the County of f jYL(, ktA State of North Carolina, hereby certify that ,- 0101.cY 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 26 day of OCAT)bfr , 20 'Z r1OTAl,y cc\ o ary SealMY COMMISSION 'Jit�/1 NEXPIRES = My commission expires � N2/27/2027 CO "13'.,may pUBLIG spy 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. Check if this project is ARPA-funded ❑ Attach a copy of the Letter of I bE . FINANCIAL RESPONSIBILITY/OWNERSHIP FORM OCT 26 SEDIMENTATION POLLUTION CONTROL ACT 2023 No person may initiate any land-disturbing activity on one or more acres as covered by the CriTitlutlityiony activity under a common plan of development of this size as covered by the NCGO1 permit, before this former -- 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. r 1. Project Name ` i n'i rh nut - Wa 'idsor f-bc Lok *If this project involves American Rescue Plan Act(ARPA) funds, list the Project Name or Project Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the Division of Water Infrastructure (DWI). 2. Location of land-disturbing activity: County OnS Il�0. W City or Township V Highway/StreetLtii , 61 LA, Latitude(decimaldegrLe1 Longltude(d�imalde es) 220 3. Approximate date land-disturbing activity will commence: II /Li/23 4. Purpose of development(residential, commercial, industrial, institutional, etc.): QS I d'enli £(, ' 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): • 21 g 6. Amount of fee enclosed: $ /i D ' U O . 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 k Enclosed No ❑ 8. Person to('íhni contact should erosion and sediment control issues arise during land-disturbing activity: Name & rd E-mail Address Cby rd @ windsw-hen-es. US Phone: Office# 17/a Mobile# WO ` & 2 Z - b 3 SZ 9. Landowner(s) of Record (attach accompanied page to list additional owners): Win rm k' u is . LL . 3310 2 2- 3535 9/U- 7y2-7/37 Name Phone: Office# Mobile# PO BMX 27!h9 !DO7 -1fraunAl Alit lull2o1 Current Mailing Address Current Street Address U1lmm►�t -vi lV6 WfO ) & ev?Jlom'z JUG 27`f aF City State Zip City State Zip 10. Deed Book No. (6 D 29 (/ Page No. d 5-.3 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). fi(dJUr Invest erth L LC, sgolserJ windsyhon?ef. of Company Name E-rtAil Address `Pao 6aX 270 /4d7 ra- u�d flint d o l Current Mailing Address Current Street Address1 i lm t�q- W401 breinfion NW 27�af� City State Zip City State Zip Phone: Office# 2310~ 2 ? 3 s- Mobile# q/to -7V 2 -7/37 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: 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. IN n i+ n ( 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. Sara &ô1r Convtru,ii. Typ or print na Title or Authority /07/2407 Signature Date I, "'1)11 ntidq r , a Notary Public of the County of 3n.Ain$1O\C� State of North Carolina, hereby certify that S va., bokcor 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 L5 day of DCtD hY , 20 ?! o````�wuttl�fl!llrl�rp�� coL a� � C ; t'o otary ti'Seal �' NOTAfb, tt� J MY My commission expires 2212� 20Z1 COMMISSION EXPIRES e ` cP 2/27/2027 ^per /'�'�9/1;C ulC tSt `,0 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.