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HomeMy WebLinkAboutNCC241574_FRO Submitted_20240523 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.) Part A. 1. Project Name Union Street Improvements 2. Location of land-disturbing activity: County: Cabarrus City or Township: Concord Highway/Street Union Street Latitude 35d24'38.54" N Longitude 80d34'52.41W 3. Approximate date land-disturbing activity will commence: June 2021 4. Purpose of development(residential, commercial, industrial, institutional, etc.): Municipal 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 3.5 6. Amount of fee enclosed: $ 260.00 . 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 J0SePt1 212EE, E-mail Address 3bnu e-Seth 0...m.410 140<<•co -. Telephone 0t SZUI 0'L Cell# 10q (os7 Fax# VOt/cZZ 5494 9. Landowner(s) of Record (attach accompanied page to list additional owners): City of Concord 704-920-5555 Name Telephone Fax Number 35 Cabarrus Ave W 35 Cabarrus Ave W Current Mailing Address Current Street Address Concord, NC 28025 Concord, NC 28025 City State Zip City State Zip 10. Deed Book No: NA/Public ROW SURVEY PROVIDED Page No. 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. SEAL-IkA a' rfoceder CQIQP. _Aso 6u_e.SPAlara Con Cfort • core •f'•0e (009 I� Address € Current Mailing Address Current Street Address (I�1014,4D 241 itapilt. rtc- 2/31 bri City State Zip City State Zip Telephone 104 . 2ZI I t1- Fax Number ibq cn. sti9q 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: Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Telephone 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 should there be any change in the information provided herein. JASonl a-Arai bi44r Type o- int name Title or Authority ae" 51, Si atu Date I, x\ \nV l 10 1► Q.\I , a Notary Public of the County of C 06Y`'US State of North Carolina, hereby certify that JAStri b -- appeared personally before me this day and being duly sworn acknowledged that the above form was executed by him. Witness my •''handt. n aO•af'd notarial seal, this IS*" day of 1Y I , 20 Z( I 111 ` ' tary = My commission expires /4/3/ 27 0's PU F3 1.\ "4.1 i nisi,0 "--� `��a