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HomeMy WebLinkAboutNCC241174_FRO Submitted_20240417 CEIVE... FINANCIAL RESPONSIBILITY/OWNERSHIP FORM JAN 28 2022 SEDIMENTATION POLLUTION CONTROL ACT La D�NR-DEMJ_R d ali No person may initiate any land disturbing activity on one or more acres as covered bye aerrA440 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. 5101 Stack Rd Lot #1 1. Project Name 2. Location of land-disturbing activity: County Union City or Township Buford Township Highway/Street Stack Rd (SR 2115) Latitude 34.827274 Longitude -80.452517 3. Approximate date land-disturbing activity will commence:September 2021 4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 0.32 6. Amount of fee enclosed: $ 195 . The application fee of $65.00 per acre (rounded up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585). 7. Has an erosion and sediment control plan been filed? Yes No Enclosed X 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name Todd Starnes E-mail Address wtstarnes@yahoo.com Telephone 843-675-7555 Cell# 704-254-6710 Fax# 843-675-7717 9. Landowner(s) of Record (attach accompanied page to list additional owners): Brother's Housing & Real Estate, Inc 843-675-7555 843-675-7717 Name Telephone Fax Number 1406 South Van L. Mungo Blvd 1406 South Van L. Mungo Blvd Current Mailing Address Current Street Address Pageland SC 29728 Pageland SC 29728 City State Zip City State Zip 10. Deed Book No. 8026 Page No. 0023 & 24 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. Brothers Housing & Real Estate, Inc wtstarnes@yahoo.com Name — E-mail Address 1406 South Van L. Mungo Blvd 1406 South Van L. Mungo Blvd Current Mailing Address _ Current Street Address Pageland SC 29728 Pageland SC 29728 City State Zip City State Zip Telephone 843-675-7555 Fax Number 843-675-7717 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: WM tijk, ---0011 511a(irVIS tit)tcbrria citronsmor Name E-mail Address ��� P r y 000 scir o Vat s lq `�'r /Ueiwo J I Current Mailing Address Current Street Address City State Zip City State Zip Telephone ��� Q� �," Fax Numbest ^ (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: WOLV(VL—II) 66‘ (5-Varing hail-4,4 LAM(qc,641 flo, t,cyyl i Name of Registered Agent E-mail Address 3ri PaithIVOOd ,-SChOD' Oci ,3M PcurrakiwcA &.-hool eci ,, I. Current�M/ailing Address p Current Street Address City State Zip City State Zip 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 iriformatio should the b any change in the information provided herein. a s „ L:51 - -nes '70 e ' J-- y e p r rrne Title or Authority. a L, •i , II Sr nature Date I, .�US7" h , a Notary Public of the County of Gkf'�e-i ela�J- - Car1(Yii ���'lt'r 6614 Sfn r )/ appeared State of - a, herebycertifythatpp personally before me this day and being duly sworn acknowledged that the above form was executed by him. Witness my hand and notarial seal, this `i day of vJ , 20 a `1/pp g dr ,,A Waton AZ:" %. to IFS I l q_ )3 ARr '^�°� � My commission expires lr I '0UB0° /