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HomeMy WebLinkAboutNCC241173_FRO Submitted_20240507 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 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 and/ or fax information unavailable, place N/A in the blank.) P1art. A.Project Name Overlook 85 North - Clearing and Grubbing 2. Location of land-disturbing activity: County Rowan City or Township Highway/Street SR2784 Latitude 35'527 Longitude-80.572 3. Approximate date land-disturbing activity will commence:3/24/2024 4. Purpose of development(residential, commercial, industrial, institutional, etc.): Industrial 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):52 acres 6. Amount of fee enclosed: $ 5,200.00 . The application fee of$100.00 per acre (rounded up to the next acre)is assessed without a ceiling amount(Example: 8.10 ac= $900.00). 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 Matthew Graham E-mail Address mgraham@burtonengineering.com Telephone 704-553-8881 Cell # Fax# 9. Landowner(s) of Record (attach accompanied page to list additional owners): HCP Kannapolis Crossing Land Ventures, LLC 919-838-7203 Name Telephone Fax Number 4350 Lassiter at North Hills Ave, suite 280 Current Mailing Address Current Street Address Raleigh Nc 27609 City State Zip City State Zip 10. Deed Book No. 1382 Page No.416 Provide a copy of the most current deed. Deed Book No. 1399 Page No. 808 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. HCP Kannapolis Crossing Land Ventures, LLC Name E-mail Address 4350 Lassiter at North Hills Ave, suite 280 Current Mailing Address Current Street Address Raleigh Nc 27609 City State Zip City State Zip Telephone 919-838-7203 Fax Number 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: Legalinc Corporate RA Services INC. Name E-mail Address 8480 Honeycutt Road, ste 200#V295 Current Mailing Address Current Street Address Raleigh, NC 27615 City State Zip City State Zip Telephone 302-894-8922 Fax Number (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: Name of Registered Agent E-mail Address Current Mailing Address 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 information s should t re be any change in the information provided herein. 2wa 3 e-2 • /Av 5 a,J 0\o.. r '� t t t-cc Ar Type or print name Title or Auth d 2-/2.5 2OZy ire Date I, -3---ESSE------CL-q-144‘,16.03 , a Notary Public f the County of I"D4L'C State of North Carolina, hereby certify that E-]?�AZ�"—b . ' appeared 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 a`1Tii- day of rii Z , 20 at/ l JESSE T. BUCHANAN NOTARY PUBLIC , WAKE COUNTY, N.C. otary Seal My commission expires ac---